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Journal of Cardiology & Clinical Research

Cite this article: Takenaka K, Murasato Y (2016) A Case of Iatrogenic Intra-Stent Coronary Dissection after Biolimus-Eluting Stent Deployment in the Left Main Coronary Artery. J Cardiol Clin Res 4(8): 1086.

*Corresponding author

Yoshinobu Murasato, Department of Cardiology, National Hospital Organization Kyushu Medical Center, 1-8-1, Jigyohama, Chuo-ku, Fukuoka, 810-8563, Japan, Tel: 81-92-852-0700; Fax: 81-92-847-8802; Email:

Submitted: 04 October 2016

Accepted: 24 November 2016

Published: 25 November 2016

Copyright© 2016 Murasato et al.

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Keywords•Intra-stent coronary dissection•Optimal coherence tomography•Drug-eluting stent•Left main coronary artery

Case Report

A Case of Iatrogenic Intra-Stent Coronary Dissection after Biolimus-Eluting Stent Deployment in the Left Main Coronary ArteryKatsuhiko Takenaka and Yoshinobu Murasato*Department of Cardiology and Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Japan

Abstract

We encountered a case of an iatrogenic intra-stent coronary dissection at the guiding catheter engagement in 6-month follow-up angiography after a biolimus-eluting stent implantation in the left main coronary artery (LMCA). The optical coherence tomography revealed peeling of the thin neointima inside the stent and thrombus formation. We made a reentry through the dissected lumen with the guide wire and dilated with balloon, which provided sufficient lumen and completion of the bail-out without additional stenting. Since the neointima is immature and fragile, we should take care for the catheter engagement to the LMCA previously treated with the drug-eluting stent.

ABBREVIATIONSLMCA: Left Main Coronary Artery; PCI: Percutaneous

Coronary Intervention; FD-OCT: Frequency Domain-Optimal Coherence Tomography; DES: Drug Eluting Stent; LAD: Left Anterior Descending artery; LCX: Left Circumflex artery; CAG: Coronary Angiography; POBA: Plain Old Balloon Angioplasty

INTRODUCTIONIatrogenic coronary dissection is rare but associated with a

potential risk of acute impairment of coronary blood flow which results in devastating complication of percutaneous coronary intervention (PCI). Its incidence has been reported 0.06% of the diagnostic or interventional coronary procedures, 0.25% of whole PCIs in recent reports [1,2]. When a guiding catheter is engaged to the coronary artery, an inappropriate maneuver is likely to occur the dissection in the ostium of the engaged coronary artery. However, after stenting at the ostium of the left main or the right coronary arteries, iatrogenic intra-stent coronary dissection has not yet been reported. Previously, there are a few case reports that spontaneous intra-stent coronary dissection was confirmed with frequency domain-optical coherence tomography (FD-OCT) [3-5], which suggested an involvement of rupture in the neoatherosclerosis lesion and reabsorption of the organized

thrombus within the stent.

We encountered an unusual complication of intra-stent coronary dissection which occurred easily after the insertion of guiding catheter in the left main coronary artery (LMCA). We assessed the dissection accurately with the FD-OCT and found a possible risk of fragility of neointima in the drug-eluting stent (DES).

CASE PRESENTATIONA 78-year-old man with hypertension and dyslipidemia

underwent the PCI for relieving angina pectoris 6 months before, in which a 3.5×24mm NOBORI stent (TERUMO, Tokyo, Japan) was implanted from the ostium of LMCA to the proximal segment of left anterior descending artery (LAD). The patient was re-admitted to our hospital for the assessment of 6-month follow-up state by angiography and FD-OCT. A 6-French guiding catheter (Heartrail II, IL 3.5, TERUMO, Tokyo, Japan) was engaged to the LMCA via right radial artery. We confirmed that GC was engaged appropriately by intial test shot, and then confirmed no serious problem. Coronary angiography (CAG) demonstrated no in-stent restenosis without any impairment of coronary blood flow at the first shot (Figure 1). However, immediately after then, the patient suffered from serious chest pain with ST-segment depression

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and wide QRS duration in broad anterior chest leads (Figure 2A). His hemodynamics was temporally collapsed due to ventricular tachycardia, which was spontaneously terminated (Figure 2B). In order to confirm the situation, secondary shot of the contrast medium was performed, which resulted in the impairment of coronary flow in whole left coronary artery (Figure 3A,B). Immediately, we tried to advance guide wires (GW) in both LAD and left circumflex artery (LCX) and succeeded in both advancements with some difficulty in the LAD. Fortunately, his hemodynamics was stabilized after GW advancement into the LAD, therefore we performed FD-OCT observation in both LAD and LCX carefully at a rate of 2 ml/sec, total amount of 5ml by an auto injector. It showed that neointimal surface in the LMCA was peeled from the stent previously implanted and divided the LMCA into two lumens with plenty of thrombus (Figure 3C). We diagnosed as intra-stent coronary dissection with impending occlusion due to the thrombus. After thrombus aspiration, we confirmed the neointimal dissection from the proximal LMCA to the proximal LAD and the entry and the re-entry point by the FD-OCT assessment (Figure 4). And then, we inflated 3.0 and 3.5mm non-compliant balloons in LAD and LMCA, respectively. We confirmed adequate luminal gain (LMCA 8.5mm2, LAD 5.1mm2) with sufficient compression of the dissected site with recanalization to the true lumen in both entry and re-entry sites. Hence, we judged that additional stenting was not necessary (Figure 5). The patient’s symptom and ST-T changes in the electrocardiogram were recovered and post-procedural creatinine phosphokinase was not elevated. After careful observation for 1 week, the patient was discharged without any adverse events.

DISCUSSIONIatrogenic coronary dissection induced by guiding catheter

insertion into the LMCA may lead to catastrophic hemodynamic loss and broad myocardial infarction. In the International Registry of Aortic Dissection report [6], iatrogenic coronary dissection was likely to occur in patients with older age, diabetes

mellitus, hypertension, and a higher degree of atherosclerosis. In the present case, the intra-stent coronary dissection occurred after the engagement of the guiding catheter and deteriorated coronary flow due to the separation of the lumen by intimal flap promoted thrombus formation in each narrowing lumen. When we encounter the iatrogenic dissection at the engagement of the guiding catheter, we should not inject the contrast media to avoid the progression of dissected lumen. However, we did not recognize intra-stent coronary dissection at first, because we engaged the guiding catheter without serious difficulty or rough maneuver and first CAG did not show any significant restenotic lesion with high risk of ostial dissection in the LMCA. Therefore we observed the lesion using the FD-OCT with the injection of contrast medium and fortunately found an intra-stent coronary dissection with high resolution image without any progression of the dissection or hemodynamic shock. The FD-OCT images

Figure 1 Left coronary angiography at 6-month follow-up period. No significant stenosis was observed in left main coronary artery. a: Right anterior oblique cranial view. b: Left anterior oblique cranial view. c: Right anterior oblique caudal view. d: Left anterior oblique caudal view.

Figure 2 a: Electrocardiogram after second shot of coronary angiography. Wide QRS duration with ST-T depression in I, aVL, and V3-6 leads is noted. b: Transient ventricular tachycardia.

Figure 3 a: Impairment of coronary flow in whole left coronary artery after second shot of contrast media. b: Pooling of contrast media (red arrow) in the left main coronary artery (LMCA). c: Optical coherence tomography (OCT) image of intra-stent coronary dissection in the LMCA (arrows) with plenty of thrombus in the lumen (triangles).

Figure 4 OCT images after thrombectomy. Panels a (proximal left anterior descending artery) and d (proximal LMCA) are the short axis images correspond to the sites where blue and red arrows indicate at panels b (long axis image) and c (3-dimentional image), respectively. Blue and red arrows indicate GW re-entry and entry points, respectively. T: true lumen, F: false lumen.

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showed that the dissection originated from the surface of the stent at the proximal LMCA and terminated with reentry into the intra-stent at the proximal LAD (Figure 4).

Cheng et al. reported that bail-out stenting was an acceptable treatment strategy with a high success rate of 84.6% and reasonable long-term outcomes with 15.4% of target lesion revascularization in patients with the LMCA dissection [7]. In the present case, the additional stenting inside the previously implanted stent should be also considered as a first option. However, we dilated LMCA-LAD and LMCA-LCX alternatively and confirmed the penetration from entry to reentry sites by POBA in FD-OCT and the enlarged lumen was reached to 8.5mm2 in LMCA, 5.1mm2 in LAD (Figure 5). Therefore we decided to leave the lesion without any more stent deployment in the dissected site. Binder et al. [8], also left a case of an iatrogenic native LMCA dissection without stenting because the minimum true lumen area was largely maintained to 7.2mm2.

Assessment of OCT in some recent studies has revealed that vessel wall injury (tissue prolapse 97.5%, intra-stent dissection flap 86.3%, edge dissection 25.0%) after DES deployment occurs more frequently than previously expected [9,10]. However, most of these injuries heal at 9-month follow up period [11]. The FD-OCT with 10-times high resolution compared to the intra-vascular ultra sound is useful to survey the delayed arterial healing, such as uncovered struts, low degree of neointimal hyperplasia, and late malapposition. This kind of incomplete healing is more frequent and persistent in DES than in bare metal stent [12]. Secondary inflammation induced by deep infiltration of the anti-proliferative drug into vessel wall and allergic reaction of polymer are suggested as possible explanations.

Compared with a conventional DES with durable polymer, the biolimus-eluting stent with a biodegradable polymer in abluminal coating was expected to lead to sufficient endothelialization in early phase and low-grade inflammation around the struts at first. However, in STACCATO study [13], a higher incidence of uncovered struts and a thinner mean neointima thickness were observed in lesions treated with the biolimus-eluting stent compared to those with the everolimus-eluting stent at 9-month follow up period. The neointimal coverage of this term may be influenced by stent strut thickness rather than by polymer coating or its biodegradable ability. Therefore, the neointima of biolimus-eluting stent might be immature at 6-month follow up period in the present case.

Figure 5 Post procedural OCT images. Panels a and b are the short axis image at the GW re-entry and entry points where blue and red arrows indicate in panel c, respectively. Both entry and re-entry points were dilated by balloon and large connection between true and false lumens was made. T: true lumen, F: false lumen.

To the best of our knowledge, this is the first report of an iatrogenic intra-stent coronary dissection at mid-term follow up period after DES deployment in the LMCA. Since the neointima inside the DES has a risk of fragility due to its thinner thickness or immaturity, we should take care for appropriate guiding catheter engagement in case of previous DES deployment in the LMCA.

REFERENCES1. Hokken RB, Foley D, van Domburg R, Serruys PW. Left main coronary

artery dissection during percutaneous coronary intervention treated by stenting. Neth Heart J. 2002; 10: 395-398.

2. Nunez-Gil IJ, Bautista D, Cerrato E, Salinas P, Verbella F, Omede P, et al. Incidence, management, and immediate- and long-term outcomes after iatrogenic aortic dissection during diagnostic or interventional coronary procedures. Circulation. 2015; 131: 2114-2119.

3. Rivero F, Cuesta J, Benedicto A, Alfonso F. Ruptured neoatherosclerosis presenting as a large intrastent neointima disssection. JACC Cardiovasc Interv. 2014; 7: 169-170.

4. Murphy JC, Bhindi R. Spontaneous Intrastent Dissection Late Neointimal Separation within a Bare Metal Stent Causing Acute Coronary Syndrome. Circulation. 2012; 125: 1586-1588.

5. Gutierrez Garcia H, Amat Santos IJ, San Roman Calvar JA. Intrastent coronary dissection assessed with optical coherence tomography. Rev Esp Cardiol. 2012; 65: 570.

6. Januzzi JL, Sabatine MS, Eagle KA, Evangelista A, Bruckman D, Fattori R, et al. Iatrogenic aortic dissection. Am J Cardiol. 2002; 89: 623-626.

7. Cheng CI, Wu CJ, Hsieh YK, Chen CJ, Chen SM, Yang CH, et al. Percutaneous coronary intervention for iatrogenic left main coronary artery dissection. Int J Cardiol. 2008: 126: 177-182.

8. Binder RK, Boone RH, Webb JG. Left main dissection conservatively managed with optical coherence tomography guidance. Catheter Cardiovasc Interv. 2014; 83: 65-68.

9. Gonzalo N, Serruys PW, Okamura T, Shen ZJ, Onuma Y, Garcia-Garcia HM, et al. Optical coherence tomography assessment of the acute effects of stent implantation on the vessel wall; a systematic quantitative approach. Heart. 2009; 95: 1913-1919.

10. Bouma BE, Tearney G, Yabushita H, Shishkov M, Kauffman CR, DeJoseph Gauthier D, et al. Evaluation of intracoronary stenting by intravascular optical coherence tomography. Heart. 2003; 89: 317-320.

11. Cock DD, Bennett J, Ughi GJ, Dubois C, Sinnaeve P, Dhooge J, et al. Healing course of acute vessel wall injury after drug-eluting stent implantation assessed by optical coherence tomography. Eur Heart J Cardiovasc Imaging. 2014; 15: 800-809.

12. Nakazawa G, Nakano M, Otsuka F, Wilcox JN, Melder R, Pruitt S, et al. Evaluation of polymer-based comparator drug-eluting stents using a rabbit model of iliac artery atherosclerosis. Circ Cardiovasc Interv. 2011; 4: 38-46.

13. Adriaenssens T, Ughi GJ, Dubois C, De Cock D, Onsea K, Bennett J, et al. STACCATO(Assessment of Stent sTrut Apposition and Coverage in Coronary ArTeries with Optical coherence tomography in patients with STEMI, NSTEMI and stable/unstable angina undergoing everolimus vs. biolimus A9-eluting stent implantation): a randomized controlled trial. EuroIntervention. 2016; 14: 1619-1626.

Takenaka K, Murasato Y (2016) A Case of Iatrogenic Intra-Stent Coronary Dissection after Biolimus-Eluting Stent Deployment in the Left Main Coronary Artery. J Cardiol Clin Res 4(8): 1086.

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