CASE20240806_004
Man Proposes but Dissection Disposes - Dissection Complication During Elective PCI
By Sujai Nikhil Ramakrishnan
Presenter
Sujai Nikhil Ramakrishnan
Authors
Sujai Nikhil Ramakrishnan1
Affiliation
KMCH Institute of Health Sciences and Research, India1,
View Study Report
CASE20240806_004
Complication Management - Complication Management
Man Proposes but Dissection Disposes - Dissection Complication During Elective PCI
Sujai Nikhil Ramakrishnan1
KMCH Institute of Health Sciences and Research, India1,
Clinical Information
Relevant Clinical History and Physical Exam
36 / Male.
Symptoms on presentation; REST ANGINA ON/OFF
Clinical diagnosis: NSTEMI (Trop-T: 563)
Comorbids: SMOKER, NO OTHER COMORBIDITIES / NO FH OF CAD / NO PAST HISTORY OF CARDIAC SIGNIFICANCE.
Physical exmaination: No Pallor; clubbing Grade I / stable vital signs.
Symptoms on presentation; REST ANGINA ON/OFF
Clinical diagnosis: NSTEMI (Trop-T: 563)
Comorbids: SMOKER, NO OTHER COMORBIDITIES / NO FH OF CAD / NO PAST HISTORY OF CARDIAC SIGNIFICANCE.
Physical exmaination: No Pallor; clubbing Grade I / stable vital signs.
Relevant Test Results Prior to Catheterization
Relevant Catheterization Findings
diagnostic angiogram:
Right dominant system; CTO of proximal RCA. collateralized well from left system.
type 3 LAD with SCAD of proximal LAD segment.
Non dominant LCx with good calibre OM branches, having another CTO of proximal LCx segment.
CAG RCA LAO.mp4
CAG PA CAUD.mp4
CAG RAO CRA.mp4
Right dominant system; CTO of proximal RCA. collateralized well from left system.
type 3 LAD with SCAD of proximal LAD segment.
Non dominant LCx with good calibre OM branches, having another CTO of proximal LCx segment.
CAG RCA LAO.mp4 CAG PA CAUD.mp4 CAG RAO CRA.mp4Interventional Management
Procedural Step
CAG SUMMARY:
TRIPLE STUMP.mp4
LM DISSECTION FLAP.mp4
FINAL PA CAUD.mp4
SCAD OF LAD
RAMUS – NORMAL
PROX. LCX – TOTAL OCCLUSION WITH COLLATERALIZED LCX DISTAL AND OM.
RCA – DOMINANT; 100% OCCLUSION WITH GOOD COLLATERALS.
PLAN OF ACTION PROPOSED:
RADIAL ACCESS - PTCA TO LCX (6F XB 3.0) AND RCA (6F JR).
IMAGING AID – NONE.
WIRES PLANNED:
RUNTHROUGH WIRE WITH BALLOON SUPPORT; GAIA FOR RCA IF IT DOES NOT YIELD TO BALLOON ASSISTED RUNTHROUGH.
ISSUES FACED:
GUIDE ENGAGEMENT IN LM DISSECTED THE DISTAL LM, LEADING TO SPIRAL DISSECTION EXTENDING INTO RAMUS AND LAD, CAUSING COMPLETE CORONARY NON PERFUSION (RCA COLLATERALIZED FROM LEFT SYSTEM)
PLAN OF MANAGEMENT:
WIRED THE LAD; POBA WITH 2.5 X 10MM NC TO RE-ESTABLISH FLOW; STENTED THE LCX TO OM WITH GAIA WIRE USAGE.
STENT TO RAMUS DONE.
SPIRAL DISSECTION OF LM MANAGED WITH STENT FROM LM TO LCX OVERLAPPING THE DISTAL STENT.
HGOOD COLLATERALS.
TRIPLE STUMP.mp4 LM DISSECTION FLAP.mp4 FINAL PA CAUD.mp4Case Summary
POINTS LEARNT
BE WARY OF GUIDE / HARDWARE BEHAVIOUR.
ALWAYS HAVE A PLAN OF ACTION / DO NOT EXPECT SMOOTH PROCEEDINGS FOR ALL CASES.
WHEN IN SOUP, RE-ESTABLISH FLOW FIRST AND DECIDE ON STRATEGY / PLAN OF ACTION NEXT / INTIAL FEW MOMENTS OF ACTION DETERMINE HOW THE CASE PROCEEDS AHEAD.
BE WARY OF GUIDE / HARDWARE BEHAVIOUR.
ALWAYS HAVE A PLAN OF ACTION / DO NOT EXPECT SMOOTH PROCEEDINGS FOR ALL CASES.
WHEN IN SOUP, RE-ESTABLISH FLOW FIRST AND DECIDE ON STRATEGY / PLAN OF ACTION NEXT / INTIAL FEW MOMENTS OF ACTION DETERMINE HOW THE CASE PROCEEDS AHEAD.
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