1. Catheter Induced
Leftmain Dissection
Leftmain Dissection
Dr. Dinh Huynh Linh
National Heart Centre Singapore
Vietnam National Heart Institute
Dr. Jack Tan Wei Chieh
National Heart Centre Singapore

2. Case presentation
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59 year old gentleman
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Thorax CT: bronchus stricture + mediastinal
lymphadenophathy. Will need lung biopsy
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NSTEMI in November 2012
Persistent AF, with history of lower limb artery thrombus. On
warfarin
MPI: inferior-lateral ischaemia.
Angiogram: DVD (RCA + LCx)
PCI in RCA CTO. EF improved, from 24 to 39%
Elective admission for staged PCI in the LCx

3. RCA CTO intervention on Nov 2, 2012
Genous 3.5 x 33 + MultiLink 3.0 x 38
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Pre-procedure
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Post-procedure

4. Scheduled PCI to mid-LCx
Supposed to be a
straightforward 15-minute
PCI case
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•Type B1 lesion
•Radial approach
•6 French sheath
•EBU 3.75 6F guide

5. Avanta Fluid Injection System
•Volume: 6 mL
•Rate: 5 mL/s
•1000 PSI

6. First injection
• Dissection?
• Air embolism?
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Suspected acute
LMCA spiral
dissection, extending
into LAD and LCx

7. Catheter induced spiral dissection of LMCA

8. Clinical course
• Acute LMCA dissection. TIMI 1
flow in both LAD and LCx
• Retrograde dissection to the
coronary sinus
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• Pt had chest pain, hypotension,
VT, then VF. Multiple
defibrillation performed
• Heparin had already been given
(5500 IU) after catheter
engagement

9. Q1: What to do next?
1. CABG
2. PCI
3. Medical therapy
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10. Q2: What to do next?
1.No mechanical circulatory
support
2.Mechanical circulatory
support: IABP
3.Mechanical circulatory
support : ECMO
4.Other opinion
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11. PCI: open question?
1.To stent backward or
forward?
2.6F or 7F guiding catheter?
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12. Q4: PCI: which guidewire?
1.Hydrophillic guidewire
2.Hydrophobic guidewire
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13. Management
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The surgical team and ECMO
team were activated
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Senior consultant was called
for help
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Strategy: Stent the LMCA,
LAD, LCx
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RFA puncture
JL 3.5 6F guide
Fielder 0.014” to distal LAD
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Genous 3.5 x 33 stent in LMCA
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The LMCA’s ostium was covered

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Restoration of LAD and LCx flow
after LMCA stenting and post-dilatation

16. Stents implantation in LAD and LCx
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Proximal LAD stent implantation (Coroflex Blue 3.5 x 19 mm)
Coroflex Blue 3.0 x 16 mm in mid LCx
Coroflex Blue 3.0 x 28 mm in ostial LCx (TAP technique)

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Final kissing balloon inflation

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Final results

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Dissection into the left coronary cusp. The right cusp was not involved
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BP 151/64/86, HR 55 bpm, SpO2 97%
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Protamin given to neutralize heparin
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IABP was not inserted due to aortic dissection and stable condition

20. Thorax CT Angiography
LMCA
Proximal ascending
aorta intramural
hematoma, from the
LMCA, extending till the
sinotubular junction

21. Post-procedural course
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Patient was clinically stable. No chest pain
ECHO: no pericardial effusion, no LV thrombus
No EKG changes
No postprocedural cardiac enzyme elevation
Patient was discharged well 4 days later, on aspirin
100 mg and clopidogrel 75 mg

22. CTA 1 month later
Complete healing of the ascending aorta
12.2012
1.2013

23. Clinical follow-up
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Follow-up CT: The intramural hematoma in the
posterior wall of the proximal ascending aorta shows
complete resolution
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Lung cancer was excluded
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Restart warfarin
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Life long aspirin. 2 months of clopidogrel
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Pt recovered uneventfully. No recurrence of angina

24. Literature review
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Catheter induced LMCA dissection:
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Urgent revascularization is mandated
0.008 to 0.02% of diagnostic catheterizations
0.06 to 0.07% of PCI
Ostial LMCA dissection is rarer than RCA dissection
Risk factors: LMCA disease, Amplatz usage, acute MI, catheter
manipulation, hard contrast injection
Retrograde dissection involving the coronary cusp or extending
up the aortic wall < 40 mm: conservative treatment
Boyle AJ et al. management. J Invasive Cardiol. 2006 Oct;18(10):500-3
prevention and Catheter-induced coronary artery dissection: risk factors,

25. What I have learnt
• Guiding catheter can be dangerous, especially if not coaxially engaged
• Vigorous contrast injection can be dangerous
• PCI is a life-saving approach for acute LMCA dissection
• Complete seal-off of the entry site, as well as the
LMCA’s origin, is important to prevent the further
extension of the dissection
• Limited dissection to the aorta can be treated
conservatively, without any surgical intervention
• Always call for help

26. Thank you!

27. Catheter Induced
Leftmain Dissection
Leftmain Dissection
Dr. Dinh Huynh Linh
National Heart Centre Singapore
Vietnam National Heart Institute
Dr. Jack Tan Wei Chieh
National Heart Centre Singapore

28. Case presentation
•
•
59 year old male
•
•
•
•
•
•
Mediastinal and hilar lymphadenophathy
Persistent AF, on warfarin. History of lower limb artery
thrombus, treated with thrombolysis
NSTEMI in November 2012
MPI: inferior-lateral ischaemia. EF=24%.
Angiogram: double vessel disease
PCI in RCA CTO
Elective admission for checking prior stents in RCA
and PCI in the LCx

29. QuickTime™ and a
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The LMCA was stented (Genous 3.5 x 33 mm at 16 atm)
Post-dilate the LMCA with Hiryu 3.5 x 15 mm NC balloon

30. QuickTime™ and a
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Proximal LAD stent implantation (Coroflex Blue 3.5 x 19 mm)

31. RCA CTO intervention on Nov 2, 2012
Genous 3.5 x 33 + MultiLink 3.0 x 38
QuickTime™ and a
H.264 decompressor
are needed to see this picture.
Pre-procedure
QuickTime™ and a
H.264 decompressor
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Post-procedure

32. Angiogram on Dec 11, 2012
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November 2
December 11

33. •
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59 year old gentleman.
Persistent AF, on warfarin
Thorax CT: suspected lung maglinancy. Will need lung biopsy
NSTEMI in November 2012 with inferior-lateral ischemia on MPI
Angiogram: DVD (RCA + LCx)
PCI in RCA. EF improved from 24% to 39%
Elective admission for staged PCI in the LCx

34. IVUS