Lmca dissection

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  • endothelial progenitor cell capturing stent
  • Senior consultant punctured the groin while main operator tried to wire via radial approach, but unsuccessful
  • ascending aorta shows complete resolution
  • The LMCA ositum: greater elastic + fibrious tissue content
  • he longest follow-up available in the literature is from the ASAN-MAIN (ASAN Medical Center-Left MAIN Revascularisation) Registry (n=250:BMS n=100, CABG n=250) [41]. In the 10-year follow-up, the adjusted risks of death (HR 0.81; 95%, CI: 0.44 to 1.50; p=0.50) and the composite outcome of death/QWMI/CVA (HR: 0.92; 95% CI: 0.55 to 1.53; p=0.74) were similar between the 2 treatment groups (BMS and CABG). Notably, the rate of TVR was significantly higher in the BMS group (HR: 10.34; 95% CI: 4.61 to 23.18;
    p<0.001). For comparison, 5-year follow-up of another population who underwent ULM PCI with DES from the same registry (n=395: DES n=176, CABG n=219) [41] demonstrated no significant differences in death (HR: 0.83; 95% CI: 0.34 to 2.07; p=0.70) or the same composite outcome of death/QWMI/CVA (HR: 0.91; 95% CI: 0.45 to 1.83; p=0.79). The rate of TVR was, however, higher in the DES group compared to the CABG group (HR: 6.22; 95% CI: 2.26 to 17.14; p<0.001); with the effect being less pronounced compared to BMS.
  • The LMCA ositum: greater elastic + fibrious tissue content
  • Lmca dissection

    1. 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. 2. Case presentation • • 59 year old gentleman • Thorax CT: bronchus stricture + mediastinal lymphadenophathy. Will need lung biopsy • • • • • 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. 3. 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 are needed to see this picture. Post-procedure
    4. 4. Scheduled PCI to mid-LCx Supposed to be a straightforward 15-minute PCI case QuickTime™ and a H.264 decompressor are needed to see this picture. •Type B1 lesion •Radial approach •6 French sheath •EBU 3.75 6F guide
    5. 5. Avanta Fluid Injection System •Volume: 6 mL •Rate: 5 mL/s •1000 PSI
    6. 6. First injection • Dissection? • Air embolism? QuickTime™ and a H.264 decompressor are needed to see this picture. Suspected acute LMCA spiral dissection, extending into LAD and LCx
    7. 7. Catheter induced spiral dissection of LMCA
    8. 8. Clinical course • Acute LMCA dissection. TIMI 1 flow in both LAD and LCx • Retrograde dissection to the coronary sinus QuickTime™ and a H.264 decompressor are needed to see this picture. • Pt had chest pain, hypotension, VT, then VF. Multiple defibrillation performed • Heparin had already been given (5500 IU) after catheter engagement
    9. 9. Q1: What to do next? 1. CABG 2. PCI 3. Medical therapy QuickTime™ and a H.264 decompressor are needed to see this picture.
    10. 10. Q2: What to do next? 1.No mechanical circulatory support 2.Mechanical circulatory support: IABP 3.Mechanical circulatory support : ECMO 4.Other opinion QuickTime™ and a H.264 decompressor are needed to see this picture.
    11. 11. PCI: open question? 1.To stent backward or forward? 2.6F or 7F guiding catheter? QuickTime™ and a H.264 decompressor are needed to see this picture.
    12. 12. Q4: PCI: which guidewire? 1.Hydrophillic guidewire 2.Hydrophobic guidewire QuickTime™ and a H.264 decompressor are needed to see this picture.
    13. 13. Management • The surgical team and ECMO team were activated • Senior consultant was called for help • Strategy: Stent the LMCA, LAD, LCx • • • RFA puncture JL 3.5 6F guide Fielder 0.014” to distal LAD QuickTime™ and a H.264 decompressor are needed to see this picture.
    14. 14. QuickTime™ and a H.264 decompressor are needed to see this picture. Genous 3.5 x 33 stent in LMCA QuickTime™ and a H.264 decompressor are needed to see this picture. The LMCA’s ostium was covered
    15. 15. QuickTime™ and a H.264 decompressor are needed to see this picture. QuickTime™ and a H.264 decompressor are needed to see this picture. Restoration of LAD and LCx flow after LMCA stenting and post-dilatation
    16. 16. Stents implantation in LAD and LCx QuickTime™ and a H.264 decompressor are needed to see this picture. QuickTime™ and a H.264 decompressor are needed to see this picture. QuickTime™ and a H.264 decompressor are needed to see this picture. 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)
    17. 17. QuickTime™ and a H.264 decompressor are needed to see this picture. QuickTime™ and a H.264 decompressor are needed to see this picture. Final kissing balloon inflation
    18. 18. QuickTime™ and a H.264 decompressor are needed to see this picture. QuickTime™ and a H.264 decompressor are needed to see this picture. Final results
    19. 19. QuickTime™ and a H.264 decompressor are needed to see this picture. QuickTime™ and a H.264 decompressor are needed to see this picture. • Dissection into the left coronary cusp. The right cusp was not involved • BP 151/64/86, HR 55 bpm, SpO2 97% • Protamin given to neutralize heparin • IABP was not inserted due to aortic dissection and stable condition
    20. 20. Thorax CT Angiography LMCA Proximal ascending aorta intramural hematoma, from the LMCA, extending till the sinotubular junction
    21. 21. Post-procedural course • • • • • 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. 22. CTA 1 month later Complete healing of the ascending aorta 12.2012 1.2013
    23. 23. Clinical follow-up • Follow-up CT: The intramural hematoma in the posterior wall of the proximal ascending aorta shows complete resolution • Lung cancer was excluded • Restart warfarin • Life long aspirin. 2 months of clopidogrel • Pt recovered uneventfully. No recurrence of angina
    24. 24. Literature review • • • • • Catheter induced LMCA dissection: • • 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. 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. 26. Thank you!
    27. 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. 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. 29. QuickTime™ and a H.264 decompressor are needed to see this picture. QuickTime™ and a H.264 decompressor are needed to see this picture. 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. 30. QuickTime™ and a H.264 decompressor are needed to see this picture. QuickTime™ and a H.264 decompressor are needed to see this picture. Proximal LAD stent implantation (Coroflex Blue 3.5 x 19 mm)
    31. 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 are needed to see this picture. Post-procedure
    32. 32. Angiogram on Dec 11, 2012 QuickTime™ and a H.264 decompressor are needed to see this picture. November 2 December 11
    33. 33. • • • • • • • 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. 34. IVUS

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