Intravascular ultrasound guided reconstruction of prior complicated right coronary intervention
Presenter
Daniel Tran, DO, Virtua Our Lady of Lourdes Hospital, Cherry Hill, NJ
Daniel Tran, DO1, Michael Lee, DO2, Troy Randle, DO1 and Yaser Alhamshari, MD3, (1)Virtua Our Lady of Lourdes Hospital, Cherry Hill, NJ, (2)Rowan University - School of Osteopathic Medicine, Stratford, NJ, (3)Einstein Healthcare Network, philadelphia, NJ
Title
Intravascular ultrasound guided reconstruction of prior complicated right coronary intervention
Introduction
Iatrogenic coronary dissection during percutaneous interventions can lead to subintimal tracking and subsequent false lumen stenting, which is associated with a 57% reocclusion rate. Intravascular ultrasound (IVUS) could differentiate between stent deployment in either the true or false lumen and decrease complications. Here we present a case where successfully recanalization of the right coronary artery (RCA) was achieved by crushing the previous IVUS identified false lumen stent.
Clinical Case
62-year-old female with extensive RCA disease complicated by dissection was managed with coronary stenting. Repeat angiography a few years later revealed RCA restenosis and concomitant left circumflex disease which was treated with coronary artery bypass grafting. She unfortunately developed recurrent shortness of breath and chest tightness with minimal exertion despite maximum tolerated anti-anginal therapy. Echocardiogram showed preserved left ventricular function without significant valvular disease. Pulmonary function testing was normal. Labs were unremarkable. Exercise Tc-99m myocardial perfusion stress showed defects in the basal to mid inferolateral and apical inferior segments with exercise limiting angina and Duke score -10. Diagnostic coronary and graft angiography revealed occluded saphenous vein graft to the posterior descending artery and severe disease of the mid to distal RCA with diffuse calcification and angiographic 90% in-stent restenosis (ISR) in the distal RCA.
Discussion
A workhorse wire was advanced to the distal RCA without difficulty. IVUS was utilized to assess mechanism of ISR. IVUS surprisingly showed that distal half of the previously placed stent is extending into the false lumen and that our workhorse wire is in the true lumen throughout. Here we decided to crush the false lumen segment of the old stent and place an appropriate size stent from the mid to distal RCA. The RCA was predilated using a non-compliant balloon which crushed the false lumen stent. Afterwards, the mid to distal RCA was stented using two appropriately sized drug-eluting stents. Final IVUS images showed excellent stent size, apposition, and expansion with a minimal stented area of the distal RCA at 8.4 mm². IVUS additionally showed the crushed segment of the old stent in the false lumen. Our patient tolerated the procedure very well. On follow up, patient reported remarkable improvement in her symptoms. False lumen stenting is a rare complication encountered when stenting a dissected vessel and can be easily avoided if IVUS is utilized prior to stenting. Furthermore, crushing and stenting over a malpositioned old stent can be safely and effectively performed if guided by intravascular imaging.