Case of Left Main Dissection Involving Whole Left Coronary Artery
Legate Philip, MBBS, Portsmouth Hospitals University NHS Trust, Portsmouth, United Kingdom
Legate Philip, MBBS, Portsmouth Hospitals University NHS Trust, Portsmouth, United Kingdom and Ali Dana, Portsmouth University Hospitals NHS Trust, Portsmouth, United Kingdom
Title
"Shredded Left Coronary" - Case of massive left main dissection involving whole coronary tree
Introduction
Left main dissection is a potentially life threatening complication of angiography . We discuss the case of an iatrogenic left main coronary dissection at the end of a diagnostic study affecting the whole left coronary tree. We hope to discuss the cause and options for management of this life threatening complication that requires quick decision making.
Clinical Case
A 58 yr old retired midwife was reviewed in the chest pain clinic with atypical chest discomfort of recent onset, at times associated with exertion. A diagnosis of unstable angina was made and she was admitted for a coronary angiogram. Her risk factors included type 2 diabetes, hypertension, dyslipidaemia, ex smoker and raised body mass index (BMI).
Coronary angiogram revealed an area of moderate atheroma in the LAD close to an area of myocardial bridging. We performed an OCT which confirmed the moderate lesion. As there were no high risk features, we decided to medically mange her in the first instance with anti anginals. Final wire out shot after OCT caused a massive LMS dissection involving the LAD and Circumflex. The patient became compromised and needed resuscitation. We discuss the challenges we had, how best to manage this and critical decision making in terms of extent of stenting .
Discussion
1. Always ensure co-axial position of the guide and be careful with the force of injection. 2. It is crucial to identify the dissection early. 3. Once recognised, stop injecting as this can propagate dissection. 4. Wire blindly using regular work horse wires. The feel of how a wire passes and if the wire goes into side branches are clues to the wire being in the true lumen. However never assume and check with IVUS. Ballooning or stenting the false lumen can lead to fatal outcomes. 5. Our powerpoint discusses stenting options. In our case we only stented the LMS and managed the other coronary dissections conservatively. 6. It's important to remember that milking of haematoma after stent deployment can compromise flow in the true lumen. This can be addressed using cutting balloons with 1:1 (or slightly smaller) ratio. 7. Good post cath lab care is paramount to case success.