alexa Left Internal Mammary Artery Dissection during Percutaneous Coronary Intervention in Hypertensive Patients | OMICS International
ISSN: 2155-9880
Journal of Clinical & Experimental Cardiology
Like us on:
Make the best use of Scientific Research and information from our 700+ peer reviewed, Open Access Journals that operates with the help of 50,000+ Editorial Board Members and esteemed reviewers and 1000+ Scientific associations in Medical, Clinical, Pharmaceutical, Engineering, Technology and Management Fields.
Meet Inspiring Speakers and Experts at our 3000+ Global Conferenceseries Events with over 600+ Conferences, 1200+ Symposiums and 1200+ Workshops on
Medical, Pharma, Engineering, Science, Technology and Business

Left Internal Mammary Artery Dissection during Percutaneous Coronary Intervention in Hypertensive Patients

Marco Vatrano1, Roberto Ceravolo1, Giuseppe Dattilo2, Vincenzo Antonio Ciconte1 and Egidio Imbalzano2*
1UTIC and Cardiology, Hospital “Pugliese-Ciaccio” of Catanzaro, Italy
2Department of Clinical and Experimental Medicine, University of Messina, Italy
Corresponding Author : Egidio Imbalzano
Unità Operativa Complessa di Medicina Interna
Azienda Ospedaliera Universitaria “Policlinico G. Martino” Via Consolare Valeria
1 98125 Messina, Italy
Tel: +393392894665
E-mail: [email protected]
Received January 23, 2014; Accepted February 18, 2014; Published February 25, 2014
Citation: Vatrano M, Ceravolo R, Dattilo G, Ciconte VA, Imbalzano E (2014) Left Internal Mammary Artery Dissection during Percutaneous Coronary Intervention in Hypertensive Patients. J Clin Exp Cardiolog 5:287. doi:10.4172/2155-9880.1000287
Copyright: © 2014 Vatrano M, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Related article at
DownloadPubmed DownloadScholar Google

Visit for more related articles at Journal of Clinical & Experimental Cardiology

Abstract

Left Internal Mammary Artery (LIMA) dissection is a potential catastrophic complication of percutaneous coronary intervention (PCI) rarely observed in hypertensive patients. There are very few reports but the paucity of data regarding the incidence capture the imagination more than other coronary dissections. Additionally, for the management of this iatrogenic complication there are no evidence-based guidelines to assist the operator. We present a case of two diagnostic catheter-induced dissections of LIMA successfully resolved with long multiple stenting, and review the existing literature. In our opinion, these case reports describe a very rare condition in hypertensive patients with some practical tips on how to avoid them, whereas there are very few published data. Moreover, we have shown that stenting has been used to solve a potentially deadly procedural complication, in a basal extremely serious clinical situation.

Keywords
Internal mammary artery dissection; Diagnostic angiography; Hypertension; Acute coronary syndrome
Case Report 1
A hypertensive and obese 58-year-old male with acute coronary syndrome without ST elevation (nSTEMI), was admitted to our department. The patient’s past medical history also included previous myocardial infarction in his 53 years, treated with primary percutaneous coronary intervention and stenting of Left Anterior Descending (LAD) coronary and, in the following years, he underwent a LIMA bypass grafting due to restenosis of previous stenting unsuitable for new percutaneous intervention. Native coronary angiography was performed by left radial access with 5Fr JL 3.5 and JR 3.5 diagnostic catheter (both Medtronic). The LIMA was easily cannulated with the same JR 3.5 diagnostic catheter. A manifold was utilized for hand injections of contrast. The first injection showed a sub-occlusive lesion of distal segment of the graft (Figure 1A). Before even proceeding with LIMA angioplasty, the patient developed severe chest pain and ST segment modification. Angiography was immediately repeated and it revealed total occlusion of proximal segment of the LIMA with TIMI (thrombosis in myocardial infarction) 0 flow (Figure 1B). Then, an Intermediate guidewire (Asahi Intecc, Japan) was passed beyond the occlusion to the LAD artery and a series of balloon inflations were carried out. With the next injection of contrast, a large spiral dissection was seen extending down the LIMA with TIMI grade I flow (Figure 1C). A decision not to stent the entire length of the LIMA was made since the dissection ended well before the baseline stenosis. The LIMA was treated with three overlapping drug-eluting stents (3.0 × 26 mm, 3.0 × 30 mm, 3.0 × 30 mm) from the distal to the proximal portion of the graft. Finally, one last drug-eluting stent (2.5 × 15 mm) was placed on the basal stenosis and the expansion of all the stents was optimized with a series of non-compliant balloon inflations with final TIMI 3 flow (Figure 1D). The patient had an uneventful post-procedural course and he has done well to date without any further complications.
Case Report 2
A hypertensive 67-year-old female with a history of coronary artery disease and coronary artery bypass grafting, was referred to our department for diagnostic angiography after a positive cardiac stress test. Native coronary angiography was performed by right femoral access with 6Fr JL 3.5 and JR 3.5 diagnostic catheter (both Medtronic). The LIMA was easily cannulated with the same JR 3.5 diagnostic catheter. A manifold was utilized for hand injections of contrast. The first and the second injection showed a patent graft (Figure 2A). The third injection of contrast showed a large spiral dissection with TIMI grade I flow to the LAD (Figure 2B). The patient developed severe chest pain and ST segment elevation. An intra-aortic balloon pump (CS100 Datascope, MaquetGentinge Group) was inserted by the left femoral artery. A decision was made to stent the entire length of the LIMA with three overlapped drug-eluting stents (2.25 × 22 mm, 2.5 × 22 mm, 2.5 × 30 mm) from the distal to the proximal portion of the graft. Finally, the expansion of all the stents was optimized with a series of noncompliant balloon inflations with final TIMI 3 flow (Figure 2C). Also this patient had an uneventful post-procedural course and she has done well to date without any further complications.
Discussion
The LIMA graft has shown superior patency rates compared to the saphenous vein graft (SVG), as reported by copious medical literature [1]. Given these results, it has become the conduit of choice for bypass of the LAD artery, with a >98% early patency rate and an 80-93% late patency rate. Furthermore, given the long life of the LIMA graft, some operators have described a growing number of diagnostic angiograms post bypass over the years, and those requiring LIMA percutaneous intervention, although rare, have increased in frequency [2,3]. However, diagnostic accuracy of multidetector Computed Tomography Angiography (CTA) has improved considerably, and the development of non-invasive diagnostic modality could reduce the necessity of diagnostic catheterization after CABG. The LIMA can be a challenging vessel to catheterize due to its acute angle of origin from the left sub-clavian artery. For graft engagement, an IMA catheter is preferred over JR as it is more co-axial and catheter manipulation should be very done very carefully to avoid complications. Another risk factor of LIMA dissection could be the catheter size. Recently, the size of the diagnostic catheter has been down-sizing progressively. Catheter-induced dissection of the LIMA was first described in 1985 and there is little published data regarding incidence in hypertensive patients of this iatrogenic complication [4-7]. More frequently, authors described spontaneous dissection of the graft. Furthermore, they suggested that multiple stenting is the best treatment for LIMA dissection [8-10]. However, long stenting is still controversial. As the LIMA dissection is catheter-induced, and is thus initiated from ostium of LIMA, if the hematoma does not compress the true lumen, and does not compromise the flow, the length of bailout stent might be able to be minimized only to cover the ostium [11]. Our two cases, therefore, add further important information regarding a complication which may be underreported due to reluctance to expose iatrogenic events. In our department, we had an incidence of iatrogenic dissection of the LIMA of about 0.01% and, given our experience, we would suggest avoiding, when possible, selective engagement of the graft, especially with an unfit catheter. We prefer to use a 5Fr IMA catheter. Furthermore, when treating a LIMA dissection, emergency bailout stenting could be the only key to obtaining a rapid coronary reperfusion and hopefully possible success.
 
References











Figures at a glance

Figure Figure
Figure 1 Figure 2
Select your language of interest to view the total content in your interested language
Post your comment

Share This Article

Relevant Topics

Recommended Conferences

Article Usage

  • Total views: 11789
  • [From(publication date):
    January-2014 - Dec 18, 2017]
  • Breakdown by view type
  • HTML page views : 8007
  • PDF downloads : 3782
 

Post your comment

captcha   Reload  Can't read the image? click here to refresh

Peer Reviewed Journals
 
Make the best use of Scientific Research and information from our 700 + peer reviewed, Open Access Journals
International Conferences 2017-18
 
Meet Inspiring Speakers and Experts at our 3000+ Global Annual Meetings

Contact Us

Agri & Aquaculture Journals

Dr. Krish

[email protected]

1-702-714-7001Extn: 9040

Biochemistry Journals

Datta A

[email protected]

1-702-714-7001Extn: 9037

Business & Management Journals

Ronald

[email protected]

1-702-714-7001Extn: 9042

Chemistry Journals

Gabriel Shaw

[email protected]

1-702-714-7001Extn: 9040

Clinical Journals

Datta A

[email protected]

1-702-714-7001Extn: 9037

Engineering Journals

James Franklin

[email protected]

1-702-714-7001Extn: 9042

Food & Nutrition Journals

Katie Wilson

[email protected]

1-702-714-7001Extn: 9042

General Science

Andrea Jason

[email protected]

1-702-714-7001Extn: 9043

Genetics & Molecular Biology Journals

Anna Melissa

[email protected]

1-702-714-7001Extn: 9006

Immunology & Microbiology Journals

David Gorantl

[email protected]

1-702-714-7001Extn: 9014

Materials Science Journals

Rachle Green

[email protected]

1-702-714-7001Extn: 9039

Nursing & Health Care Journals

Stephanie Skinner

[email protected]

1-702-714-7001Extn: 9039

Medical Journals

Nimmi Anna

[email protected]

1-702-714-7001Extn: 9038

Neuroscience & Psychology Journals

Nathan T

[email protected]

1-702-714-7001Extn: 9041

Pharmaceutical Sciences Journals

Ann Jose

[email protected]

1-702-714-7001Extn: 9007

Social & Political Science Journals

Steve Harry

[email protected]

1-702-714-7001Extn: 9042

 
© 2008- 2017 OMICS International - Open Access Publisher. Best viewed in Mozilla Firefox | Google Chrome | Above IE 7.0 version