RC

A 64-year-old female, hypertensive, diabetic, with degenerative disc disease was admitted for nerve root decompression. During hospitalization, the patient complained of chest heaviness and shortness of breath and was managed as a case of ACS-NSTEMI. Physical exam was unremarkable and vital signs were stable. She was referred for coronary angiogram prior to the spine surgery.

HS-Trop I: 1735 ng/LECG: Sinus rhythm, CRBBB2D-ECHO: Normal left ventricular geometry. Adequate wall motion and contractility. 67.2% ejection fraction by Simpson’s. Grade I diastolic dysfunction. Normal right ventricle.

The LMCA appears disease-free. The LAD is a type III vessel that has a diffusely diseased proximal to mid segment.The LCx has severe stenosis at the mid segment, ostial OM1 and mid OM2.The RCA is diffusely diseased with severe stenosis at the proximal and late mid segments. Successive images showed a filling defect extending from the ostium to the distal segment with loss of visualization of one of the RPL branches. There is also note of contrast staining into the aortic wall.

A Heartrail II (Terumo, Japan) JR4 6F guiding catheter was used to engage the right coronary ostium. A SION Blue (Asahi Intecc, Japan) coronary wire was inserted up to the distal end of the vessel.Intravascular Ultrasound using a Refinity IVUS catheter (Philips, San Diego, CA USA) of the proximal to late mid segment showed areas of dissection and hematoma on pullback with a minimum lumen area of 2.2 mm² at the tightest segment.Floating wire technique into the aorta was done using another SION Blue wire.An NC Euphora (Medtronic, Minneapolis, MIN, USA) 2.5x20 mm balloon was used to pre-dilate the ostial to mid segment at 20 atm (2.36mm). A Resolute Onyx (Medtronic, Minneapolis, MIN, USA) 2.5x38 mm DES was deployed at the ostial to late proximal segment at 24 atm (2.85mm).There were still filling defects at the late mid to distal segment on angiography, hence, the mid to early distal RCA was then pre-dilated using an NC Euphora 2.25x20 mm balloon inflated at 24 atm (2.42 mm).A Resolute Onyx 2.25x26 mm DES was deployed at the mid to early distal segment at 18atm (2.45mm).Final IVUS run showed well-apposed stent struts with a minimum stent area of 5.2 mm².Final angiographic image showed well-apposed stents with no residual stenosis and TIMI 3 flow up to the distal segment. No further filling defects were seen across the vessel.

Iatrogenic catheter-induced coronary artery dissection is a significant but uncommon side effect of coronary angiography. During regular coronary angiography, the incidence of coronary artery dissection has been found to be around 0.1%, with the right coronary artery dissection being more often than the left. The most common cause of this is mechanical damage to the artery wall brought on by the manipulation of either a wire or a catheter.  Immediate recognition as well as the decision to do stenting may be a reasonable option and should be considered early but will also depend on the extent of the dissection as well as the clinical and hemodynamic status of the patient.