Left guide catheter tip induced (Razor blade effect) causing aorto-left main coronary artery (LMCA) dissection can lead to no flow in the left coronary artery which is life threatening complication and must be bailed by immediate stenting or surgery. A 59-year-male patient presented with crescendo angina having history of stenting to left anterior descending coronary artery (LAD) using 3x23mm drug eluting stent 5yrs back. Coronary angiogram revealed 100% instent re-stenosis of the LAD stent and left circumflex (LCX) coronary artery had proximal chronic total occlusion with J-CTO score of ≥2 and dominant right coronary artery (RCA) was normal. LMCA dissection was noticed after stenting of the proximal LCX followed by abrupt retrograde extension into aorta resulting no flow in left coronary. The true lumen of LMCA was re-wired and timely bail out stenting from LMCA to LCX was performed.

1. A BAIL OUT LEFT MAIN
CORONARY ARTERY STENTING
Dr Ramachandra Barik, Associate Prof
Dept Of Cardiology
All India Institute Of Medical Sciences,
Bhubaneswar

2. CLINICAL PROFILE
• 59yrs/m
• 2015: CAD, AWMI ,HFrEF, S/P PTCA+stenting LAD one
DES,2.75x30mm treated outside
• 2019 :Increasing SOB and angina
• ECG: Old AWMI(4th universal definition)
• ECHO :RWMA IN LAD territory ,EF:25-30%
• CAG : 100%,LCX:CTO and RCA : Normal
• STRESS MPI :Significant hibernating myocardium
• He did not give consent for CABG despite heart team
suggestion
• Plan: PTCA to LAD/LCX with informed consent

3. FAILED TO CROSS TO CROSS LAD ISR ,LCX WAS STENTED USING 3X20MM
ORSIRO STENT

4. HIBERNATING MYOCARDIUM IN LAD/LCX AREA GAVE US
SOME TIME TO WIRE THROUGH TYPE-F DISSECTION

5. LMCA TO LAD AREA WAS PREDILATED BEFORE LMCA TO
LCX STENTING

6. FINAL RESULT:GOOD ANGIOGRAGHY WITH SETTLING
AORTIC DISSECTION

7. PATIENT WAS WATCHED IN WARD FOR FOUR DAYS
• NoAngina or other symptoms
• Serial 2D echo :Dissection is not visible (resolving)
• Discharged on 4th-day of the procedure
• Secondary prophylaxis for CAD
• GDMT based HF Rx with 4 pillars
:ARNI+BB+MRA+SGLT-2i

8. TAKE HOME
• Completed 6months
Follow up
• No angina or
significant SOB
• Serial echo showed
No dissection
• Guide catheter tip
induced type-II aorto-
coronary dissection due
to razor blade effect is a
treatable emergency
• Timely detection is key
• Serial ECHO is must