TS

A 53-year-old man was planned for staged PCI to distal LCx. He had a history of primary PCI, underwent stent implantation at the ostial LAD six months ago. Cardiovascular risk factors were hypertension and smoker. His vital sign and physical examinations were within normal limits.

An echocardiogram revealed a mid-range ejection fraction of 41% and regional wall motions abnormalities (hypokinetic at anteroseptal and inferolateral wall).

Coronary angiogram revealed mild to moderate stenosis at distal Left Main (LM). Stent at proximal LAD was patent with moderate stenosis at ostial LAD. There was a moderate stenosis at ostial LCx and significant stenosis at distal LCx. CTO RCA was visualized with collateral from LCx. Hence, we proceed with PCI to LCx. OCT study to LAD was performed before PCI LCx, but there was difficulty in delivering the catheter and it was displaced, knocked into the ostial LCx (Figure 1A).
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The guiding catheter was repositioned and after a more co-axial engagement, the OCT catheter was subsequently successfully advanced to distal LAD. The OCT run revealed fibrotic plaque at ostial LAD with MLA of 2.92 mm² and eccentric lesion at distal LM with MLA of 5.06 mm². An intimal tear at the ostial LCx was also visualized (Figure 2). Careful contrast injection revealed dissection at the ostial-proximal part of LCx with the reduced antegrade flow and compromised collateral flow to RCA (Figure 1B). The patient was experiencing chest pain with ECG that revealed ST elevation at the inferior lead.Wiring to LCx was performed with multiple guidewires to ensure the wire was in the true lumen. Afterward, predilation with a 2.5/15mm semi-compliant balloon was performed and a 2.25/18 mm Resolute Integrity (Medtronic, USA) was implanted at distal LCx. DK-culotte stenting technique began with a3.0/33 mm Xience Xpedition LL (Abbott Vascular, USA) placed at LCx-LM, followed by POT and first kissing balloon. After rewiring to LAD, OCT study was performed to ensure that the rewiring was performed to the distal cell. Next, a 3.5/23mm Xience Xpedition was placed at LAD-LM, followed by re-POT, kissing balloon, and a final POT (Figure 3).The patient was stabilized. The final angiogram revealed good results, and the final OCT evaluation revealed good stent expansion and apposition, no stent deformation nor jailed strut (Figure 4). 

Despite its benefit, complications may be associated with the use of OCT. According to our knowledge, this is the first case describing ‘off-track’- OCT catheter–induced coronary dissection in LM bifurcation. This may be associated with the eccentric distal LM lesion creating a complex intraluminal route for the OCT catheter delivery. DK-culotte stenting is a feasible technique in managing complications as ostial LCx dissection in LM bifurcation lesion.