Management of LCA-LM dissection.

Bogdan GoryckiBogdan Gorycki

American Heart of PolandAmerican Heart of Poland

Ustron, PolandUstron, Poland

Case report

42 years old female42 years old female Effort angina, diseaness, syncopeEffort angina, diseaness, syncope HypertensionHypertension Diabetes mellitus Diabetes mellitus HypothyreosisHypothyreosis Overweigth (body weight 120 kg)Overweigth (body weight 120 kg)

Non-invasive tests

UKG: LV function normalUKG: LV function normal EKG: ST/T changes at restEKG: ST/T changes at rest Spiral CT: hypoplasia of left vertebral Spiral CT: hypoplasia of left vertebral

artery, no significant lesion in carotid artery, no significant lesion in carotid arteries, right vertebral artery ostial lesion.arteries, right vertebral artery ostial lesion.

Further diagnosis

The patient scheduled for coronary artery The patient scheduled for coronary artery and carotid/vertebral angiogragphyand carotid/vertebral angiogragphy

LCA: RAO30, Caudal 15

LCA: LAO 55, Cranial 22

Dissection LAD/D1

Dissection LM/Cx

Time: 22:50

Fast diagnosis and problem solving

Diagnosis:Diagnosis:Spiral dissection of LM, LM bifurcation, Spiral dissection of LM, LM bifurcation, proximal Cx and proximal LAD/D1proximal Cx and proximal LAD/D1

Management:Management:-stop diagnostic procedure-stop diagnostic procedure-immediate proceeding to LM stenting:-immediate proceeding to LM stenting:

-6F JL Guiding catheter-6F JL Guiding catheter-two soft wires (BMW, Guidant)-two soft wires (BMW, Guidant)

Fast wiring of LAD and Cx

Time: 22:55

Aortic pressure:90/50 mmHgHR: 110/minECG: ST elevation.Chest pain treated with analgetics.

Direct stenting LM/LAD

BX Velocity 3.5x23mm18 atm., 15 sec.

After LM/LAD stenting

Time: 22:57

Aortic pressure:80/40 mmHgHR:120/min.

Aortic pressure:100/60 mmHgHR 90/min.

Time: 23:00

Cx stenting

Re-wiring Cx wire and predilatationOstium Cx with2.5 balloon

Stent Bx Sonic 3.5x13mmin position.

Final result:

LCA:RAO30, Caud22 LCA: LAO52, Caud 14

Time: 23:16

One-stage VA stenting:

Ostial stenosis (90%)of right VA artery

Direct stenting: BX Velocity 4.0x13mm

Conclusions

LM stenting is life saving procedure in LM stenting is life saving procedure in patients with LM dissection which occurs patients with LM dissection which occurs during diagnostic or therapeutic during diagnostic or therapeutic percutaneous coronary intervention.percutaneous coronary intervention.

The procedure should be included to routine The procedure should be included to routine training and practice.training and practice.