Chen

A 67 y/o woman, non-smoker, has history of diabetes, hypertension, hyperlipidemia. She had stented a DES at RCA one year ago due to unstable angina. In recent months, she presented with recurrent angina even with optimal medication. Physical examination revealed grade II systolic murmur at apex and lower left sternal border. ECG: sinus rhythmEchocardiography: normal ejection fraction, mild MR and TR

LMCA: atherosclerosisLAD: tubular eccentric stenosis, max 70% at P/3; diffuse eccentric stenosis, max 50% at M~D/3LCX: Near total occlusion at Ostium; tubular eccentric stenosis, max 50 % at M/3RCA: s/p stenting without significant ISR at P/3 and M~D/3; total occlusion at PL

Used right femoral artery approach with EBU 3.0 7 F (side hole), SION wire to d-LCX, dilated by 2.0 x 15 mm balloon (un-dilatable). Rotational atherectomy done by 1.25 mm burr ( 100,000~120,000 rpm) for 3 times with Rota extrasupport wire.  P-LCX lesion was dilated by 2.25 x 15 mm NC balloon, but m-LCX still presented an un-dilatable lesion. Increased the balloon pressure to 26 atm but it ruptured and causing coronary dissection. IVUS showed a p-LCX dissection at the m-LCX.  Stented a 2.5 x 48 mm DES at p~m-LCX.  Post-dilation by 2.5 x 12 mm NC balloon but  m-LCX stent still not fully expand, however, TIMI 3 flow presented.SION blue wire to d-LAD, IVUS showed MLA was 1.91 mm2 and 270-degree circumferential calcification. Rotational atherectomy was performed at LAD (96,000 ~ 144,000) for 6 times with Rota extrasupport wire. Then POBA with 2.25- and 2.5-mm NC balloon.  M-LAD stented by 2.25 x 38 mm DES and p~m-LAD stented by 3.0 x 35 mm DES. IVUS showed good stent apposition.  However, IVUS was stuck when pulled back and can’t be advanced. Thus, we pulled the wire, IVUS system and guiding catheter all together and pulled it out successfully. It caused a discrete longitudinal stent deformation. Wiring to distal LAD but failed to advance a 2.0 mm un-inflatied balloon, believe it was at false lumen, rewiring several times until balloon be advanced smoothly.  The deformed stent dilated by 2.0 x 15 mm balloon and 2.5 x 12 mm NC balloon, then stented another 2.5 x 8 mm DES. Finial CAG showed TIMI 3 flow.

An NC balloon rupture caused by high pressure resulted in coronary dissection, which was treated with stenting.There was a risk that the IVUS sheath would stuck by stent especially before adequate post dilation. To pull the IVUS back, we withdraw the IVUS catheter, wire, and guiding catheter together. However, the step causing the longitudinal deformation of the stent. After wiring to true lumen, we placed another stent overlapping the reformatted stent. Perhaps there was another better way to resolve the stuck IVUS, such as wiring another wire, and inflating a balloon at the stuck spot.