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CASE20200912_092
Complications - Complications
Life Threatening Coronary Artery Dissection Post Drug Coating Balloon in a Very Young Patient with NSTEMI
Heng Shee Kim1, Mahadevan Gurudevan1, Benjamin Leo Cheang Leng2, Chuey Yan Lee1
Hospital Sultanah Aminah, Malaysia1, Sultanah Aminah Hospital, Malaysia2,
[Clinical Information]
- Patient initials or identifier number:
Vad
-Relevant clinical history and physical exam:
A 24-year-old man with no past medical history presented with typical angina chest pain. He has no cardiovascular risk factor except a chronic smoker of 10-packs-year. Physical examination was unremarkable. 
-Relevant test results prior to catheterization:
ECG showed progressive T-inversion indicating Wellen's Type A ECG over the anterolateral lead with elevated hsTrop-T. He was treated as NSTEMI with DAPT and fondaparinux. He was planned for in-patient CAG.
- Relevant catheterization findings:
CAG showed 80%stenosis of ostial LAD with normal LCx and RCA. In view of young age, we decided for DCB strategy if feasible afterlesion preparation, keep in view bailout with DES or emergency CABG.
[Interventional Management]
- Procedural step:
LCA engaged with EBUguiding catheter 3.5mm 6F, LAD wired with BMW II and LCx with PT II wire.Pre-dilated ostial LAD and pLAD with NC 3.5x15 balloon up to 12 atm. Postdilatation noted less than 20% residual stenosis. We decided to implant SeQuent Please NEO DCB 3.5x25 to ostial LADartery at 6 atm for 60 seconds. There is a type B coronary artery dissectionpost DCB. After 15 minutes, the patient remains asymptomatic, no new ECGchanges and not worsening coronary artery dissection, we decided to end thecase. However, after 10 minutes, the patient complained of severe angina which not relieved with IV morphine, and repeats ECG showed ST elevation over the anterior lead. 
He was brought in for emergency CAG with XB 3.5 7F, noticed ATO of ostial LAD. LAD was wired with BMW II, LCX PT II. Few rounds of thrombus aspiration were performed but failed to aspirate any thrombus and remained in TIMI 0 flow. Ostial LAD pre-dilated with 3.0x15 SC, noted only TIMI I flow. We decided to stent LM to pLAD with 4.0x38 DES. While post-dilating left main, he developed VF. The stent balloon immediately deflated and CPR performed. He regained full GCS after 2cycles of defibrillation and CPR. Repeat CAG showed TIMI III flow. LM-LAD stent further post-dilated with NC 4.5x10 up to 18atm. He was well post-procedure with unsupported vital signs and resolution of ST-elevation. His echocardiogram showed good function with no wall abnormalities.
- Case Summary:
Management of CAD in very young patients remains challenging, and this case illustrates the dilemma in treating this group of patients with DCB vs DES strategy. Besides, our case also demonstrated the almost life-threatening progression of benign coronary artery dissection (Type A-B) to acute total occlusion of the coronary artery. Vigilant post-PCI monitoring of this group of patients remains relevant.

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