Abstract
Background: Iatrogenic left main coronary artery (LMCA) dissection is a rare but serious complication of coronary angiography, especially when extending into the left anterior descending (LAD) artery. While coronary artery bypass grafting (CABG) is the standard treatment for extensive LMCA dissections, percutaneous coronary intervention (PCI) may be a viable alternative in select cases.
Keywords
iatrogenic left main coronary artery dissection, type D dissection, PCI vs CABG
Case summary
A 48-year-old male with hypertension and smoking history presented with acute inferior myocardial infarction. After failed fibrinolysis, he underwent rescue PCI, during which an iatrogenic Type D LMCA-to-LAD dissection occurred due to improper Tiger catheter positioning. Given the urgency and high surgical risk, emergency PCI with stent implantation successfully restored TIMI III flow. The patient remained stable, with no complications at one- and six-month follow-ups.
Conclusion
While CABG is preferred for LMCA dissections, this case highlights PCI as an effective alternative in high-risk patients requiring urgent revascularization. Further studies are needed to refine selection criteria.
Introduction
Iatrogenic left main coronary artery (LMCA) dissection is a rare but critical complication that can occur during coronary angiography or percutaneous coronary intervention (PCI). This complication requires prompt identification and immediate intervention, as delayed treatment can lead to severe outcomes, including myocardial infarction (MI), hemodynamic instability, and even death. The incidence of LMCA dissection is estimated to be around 0.02% [1], but its potential severity makes it a major concern in interventional cardiology.
Such dissections typically result from improper catheter manipulation, particularly the incorrect placement of the catheter tip at the ostium of the left main coronary artery, leading to arterial injury [2,3]. The management of iatrogenic LMCA dissection has traditionally relied on coronary artery bypass grafting (CABG), especially when the dissection extends to the left anterior descending (LAD) artery [4]. However, PCI has emerged as a viable alternative in select cases, offering advantages such as rapid revascularization and lower procedural morbidity, particularly when surgery is deemed high-risk or not immediately feasible.
In this case report, we present a 48-year-old male patient with a history of hypertension and smoking, who developed a Type D LMCA to LAD dissection as a complication of PCI performed for acute inferior myocardial infarction after failed fibrinolytic therapy. We discuss the clinical course, the decision-making process, and the successful management of this challenging complication using PCI.
Case presentation
Patient history: A 48-year-old male smoker with a history of hypertension and no family history of cardiovascular diseases presented to the hospital for evaluation of chest pain. The patient reported that the pain started at 3 AM and radiated to both shoulders, accompanied by sweating, shortness of breath, nausea, and pallor.
Initial vital signs and laboratory results: Upon admission, the patient’s vital signs and laboratory results were as follows:
Blood Pressure (BP): 90/60 mmHg
Pulse Rate (PR): 90 bpm
Oxygen Saturation (SpO2): 95%
Creatinine (CR): 1.1 mg/dL
Potassium (K): 4.0 mEq/L
Hemoglobin (Hb): 11.5 g/dL
Fibrinolytic treatment at the referring hospital: Based on the clinical symptoms and ECG findings, a diagnosis of inferior wall myocardial infarction (MI) was made. After stabilizing the patient’s vital signs, fibrinolytic treatment was initiated at the referring hospital at 4 AM.
Referral to our hospital for salvage PCI: The patient was referred to our hospital on the same day for salvage PCI.
Pre-procedure evaluation: The left ventricular ejection fraction (LVEF) was measured at 50%, and no significant valvular heart disease was observed. Pre-procedure electrocardiogram (ECG) showed normal sinus rhythm, left axis deviation, QR complex abnormalities, ST elevation, and T-wave inversion in the inferior leads, indicating myocardial ischemia post-fibrinolysis (Figure 1a).
ECG changes after PCI: The post-procedure ECG showed a decrease in the ST segment in leads I and aVL, indicating improvement in ischemic changes following a successful PCI (Figure 1b).
Figure 1. Electrocardiogram (ECG) changes before and after rescue Percutaneous Coronary Intervention (PCI). 1a: Pre-procedural ECG showing normal sinus rhythm, left axis deviation, QR complex and ST elevation, and T wave inversion in the inferior leads, indicative after fibrinolytic therapy. 1b: Post-PCI ECG revealing ST segment depression in leads I and AVL
Procedure Details: The patient was transferred to the catheterization lab, and a 6F sheath was placed in the right radial artery. Angiography was performed using a Tiger catheter. During the third contrast injection for angiographic imaging, the patient experienced sudden chest pain. Upon immediate evaluation, an iatrogenic dissection of the left main (LM) artery into the left anterior descending (LAD) artery was identified (Figure 2a).
Figure 2. Procedural images during management of iatrogenic Left Main (LM) to Left Anterior Descending (LAD) artery dissection. 2a: Coronary angiogram illustrating the iatrogenic dissection from the LM to the LAD during contrast injection, 2b: Pre-dilation with a Selethru NC balloon on the LAD, 2c: Stenting LM to ostial of LAD, 2d: Stent of LAD, 2e: Primary outcome of stenting before POBA, 2f: Post dilation of LM, 2g: Final outcome of LM to LAD stenting
Immediate intervention
An XB6 (3.5) guiding catheter was inserted into the left main artery.
Pre-dilatation with a Selethru NC balloon (2.25 x 20 mm) was performed in the LAD.
A Firehawk stent (4 x 23 mm) was placed in the left main artery (LM).
A Greater stent (3.5 x 24 mm) was considered for LAD angioplasty.
Post-stenting balloon dilatation was performed using Apollo NC balloons (5 x 12 mm) and Genoss NC balloons (3.5 x 12 mm) (Figures 2b to 2g).
Intervention in right coronary artery (RCA): Access to the RCA was achieved using an RJ6 (3.5) catheter, revealing a dominant RCA. A Biomime stent (3.0 x 2.5 x 50 mm) was deployed for treatment of the proximal lesion. Various wires, including BMW, Tabeeb, and Whisper Extra 0.014, were used during the procedure. Successful restoration of blood flow with TIMI flow grade III was achieved in both the LM to LAD and RCA (Figure 3).
Figure 3. Angiographic images and intervention in the Right Coronary Artery (RCA) four days post initial procedure
Post-procedure care and follow-up: The patient was transferred to the coronary care unit (CCU) and remained under close observation for the following week. Follow-up echocardiography showed that the LVEF remained stable at 50%, with no significant reduction in ejection fraction or evidence of valvular heart disease.
Post-PCI ballooning in RCA: Four days after the initial PCI, post-dilatation in the RCA was performed using Apollo NC balloons (3.25 x 20 mm), Simpass NC balloons (3.5 x 12 mm), and Sequent Neo NC balloons (2.75 x 20 mm).
Follow-up visits: At the one-month and six-month follow-up visits, the patient showed no signs of decreased ejection fraction and did not report any recurrent symptoms (Figure 4).
Figure 4. Follow-up outcomes and interventions post-coronary interventions. 4a-4c: Angiographic images displaying the post-dilation of the Right Coronary Artery (RCA). 4d and 4e: Rechecking the LM coronary during post dilation of RCA
Results and discussion
In this study, the decision to perform PCI instead of coronary artery bypass grafting (CABG) in a patient with acute myocardial infarction and iatrogenic dissection of the left main (LM) to left anterior descending artery (LAD) was made. This decision was based on the priority and importance of quick intervention in critical conditions and the presence of severe complications such as dissection. In such cases, PCI has significant advantages over CABG due to its ability to provide rapid and direct intervention [5-9].
In fact, in urgent and acute situations where immediate restoration of blood flow to the heart is needed, PCI can serve as a more effective and faster option compared to CABG. While CABG remains the standard treatment for patients with complex coronary artery disease, PCI, with its shorter procedure time and lower risk, is highly preferred in cases where prompt intervention is crucial.
One of the key factors in the success of PCI in this case was the skill and coordination of the interventional team. The team's ability to quickly identify the dissection and perform the necessary interventions in a timely manner helped prevent severe complications and stabilize the patient’s condition. This highlights that with skilled teams and well-equipped centers, PCI can be preferred over CABG in treating more complex dissections and heart conditions, especially in emergency situations.
Conclusion
Ultimately, this study emphasizes that PCI, when performed by skilled interventional teams and in well-equipped centers, can serve as a first-line option for treating many acute cases, especially in type D dissections and other dissections that previously required surgical intervention. Considering the higher risks and complications associated with CABG, PCI can be used as an alternative method with lower risks and shorter procedure times, potentially replacing surgery in these cases in the future.
Author contributions
1. Ezzat rezai monfared: Principal author, drafted the manuscript, sourced and edited clinical images, results of clinical investigations, and diagrams, and critically revised the manuscript.
2. Alireza Bakhshi: Contributed to the clinical management of the patient, reviewed the manuscript, provided feedback, and approved the final version.
Supplementary material
Short videos detailing the entire procedural process are available in Supplementary file 1. The images related to this case are provided in a separate Supplementary file.
Conflicts of interest
The authors declare no competing interests related to this case report.
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