A 71-year-old female was brought to the ER with angina, dyspnea and an ECG showing ST elevation in the inferior leads. She was hemodynamically stable and was immediately transferred to the catheterization laboratory. The coronary angiography via femoral approach showed a right dominance and a 3 vessel disease with a tight proximal RCA stenosis, a distal thrombotic closure of the circumflex artery and a tight bifurcation stenosis of the LAD.
Due to the right dominance we decided to start treating the RCA and afterwards to open the closed far distal circumflex artery.
Using a JR4 guiding catheter we were able to reach the ostium, wire the RCA and started the dilatation. Upon dilatation a local dissection was observed, which initially didn´t cause any problems, since the intention was to provide the entire affected segment with a DES. Placing the DES proved to be challenging since it led to complete system displacement in the ascending aorta causing a large spiral dissection of the RCA starting proximally and reaching the distal middle segment. That led to circulatory and chronotropic depression. Intravenous fluids and atropine were administered and immediate action regarding the further intervention was undertaken.
We switched to an AL1 guiding catheter for better back up, carefully wired the RCA and proved the correct lumen location using a micro catheter. We then performed serial balloon angioplasties working our way from the distal to the proximal segments and finally carried out the implantation of 3 drug eluting stents from the distal to the proximal segments. These measures led to a normal TIMI III flow in the RCA without any remaining dissection. Furthermore the circulatory situation could be improved. Unfortunately the patient kept complaining about angina pectoris.
Using the same AL 1 guiding catheter we then proceeded to intubate the left main artery with the intension of treating the remaining distal circumflex lesion. We did so by wiring the vessel and performing balloon dilatation of the distal, mid and proximal segments followed by stenting in the exact order. The final scene showed a TIMI III flow in the entire Circumflex; although the end segment appeared very narrow (spasm?).
We conclude that evaluating the area supplied by the target lesions can change the order of the vessels to be treated even in the onset of STEMI. Having an escape algorithm in case of coronary dissection can help shorten the ischemia time and save lives.