MA

We started with the LAD CTO lesion, and we went for a bilateral radial access, with XB 3.5 6Fr to LM and A JR to RCA for retrograde injection, we adopted the antegrade wire escalation approach. The procedure went smoothly, and a GAIA II wire successfully reached distal LAD true lumen and then exchanged with a work horse wire. Two stents were deployed successfully, and the final LAD result was particularly good.Then we decided to treat the CX lesion, so another workhorse wire was advanced to distal CX, Afterwords patient developed chest pain, an angiogram showed dissection in distal LM but with sufficient flow to both LAD and CX.We were not sure if the dissection was due to the deeply engaged guiding catheter or the CX guide wire, and the doubt arises if the dissection is toward the LAD or toward the CX!So, we decided to use IVUS to understand more, and it confirms the dissection is in the LM body and the CX ostium is not affected, so we decided to stent LM-LAD to cover the dissection followed by the standard techniques of provisional stenting.Then we treated the CX lesion with another stent, after which patient developed another attack of chest pain and angiogram showed TIMI I flow in the CX and another time the IVUS come in handy and confirmed no proximal or distal edge dissection and so medical treatment in the form of IC nitrates and verapamil improved distal flow (TIMI III) and patient was discharged safely.

Extra backup guiding catheters are injuries so the operator should be careful regarding deep intubation and apply safety measures such as the floating wire technique if applicable to protect against deep intubation. When you suspect dissection get imaging and avoid more injections.When doing PCI with one of these guiding catheters, we recommend to always have a final caudal view to check the integrity of the LM at the end of the procedure.  Rapid intervention with stenting to seal the dissection flap is a life-saving measure.