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Right Coronary Artery Dissection Caused by Catheter: a Case Report Xiaozeng Wang Haiwei Liu and Yaling Han Department of Cardiology, Shenyang Northern Hospital

Right Coronary Artery Dissection Caused by Catheter: a Case Report Xiaozeng Wang Haiwei Liu and Yaling Han Department of Cardiology, Shenyang Northern

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Page 1: Right Coronary Artery Dissection Caused by Catheter: a Case Report Xiaozeng Wang Haiwei Liu and Yaling Han Department of Cardiology, Shenyang Northern

Right Coronary Artery Dissection

Caused by Catheter: a Case Report

Xiaozeng Wang Haiwei Liu

and Yaling Han

Department of Cardiology,

Shenyang Northern Hospital

Page 2: Right Coronary Artery Dissection Caused by Catheter: a Case Report Xiaozeng Wang Haiwei Liu and Yaling Han Department of Cardiology, Shenyang Northern

64-year-old male ; ID : 2163956

Chest pain for 10 months,

worsen for two months ;

Hypertension for 15 years ,

No history of diabetes ;

ECG : no ST-T segment changes

Case presentation

Page 3: Right Coronary Artery Dissection Caused by Catheter: a Case Report Xiaozeng Wang Haiwei Liu and Yaling Han Department of Cardiology, Shenyang Northern

LCA 及 RCA 动脉粥样硬化改变, RCA 造影管与 RCA 近段成角,同轴差

Feb 26, 2009 SCA : Initial angiography demonstrating atherosclerosis changes in LCA and RCA. Angularity was viewed between the angiography catheter and the proximal RCA, without ideal co-axis.

Page 4: Right Coronary Artery Dissection Caused by Catheter: a Case Report Xiaozeng Wang Haiwei Liu and Yaling Han Department of Cardiology, Shenyang Northern

RCA dissection formation from the proximal to the distal part of the vessel

Feb 26, 2009 SCA

Page 5: Right Coronary Artery Dissection Caused by Catheter: a Case Report Xiaozeng Wang Haiwei Liu and Yaling Han Department of Cardiology, Shenyang Northern

The National Heart, Lung and Blood Institute (NHLBI) Type A 血管腔内出现小的可透过区,对比剂通过即消失 dissections represent minor radiolucent areas within the coronary

lumen during contrast injection with little or no persistence of contrast after the dye has cleared.

Type B 血管腔内对比剂滞留,平行于管壁,几个周期后消失 dissections are parallel tracts or a double lumen separated by a

radiolucent area during contrast injection, with minimal or no persistence after dye clearance.

Type C 夹层突出于管壁外,对比剂通过后仍持续存在 dissections appear as contrast outside the coronary lumen

(“extraluminal cap”) with persistence of contrast after dye has cleared from the lumen.

Type D 螺旋型夹层,伴与不伴对比剂滞留 dissections represent spiral (“barber shop pole”) luminal filling

defects, frequently with excessive contrast staining of the dissected false lumen.

Type E 持续管壁充盈缺损,伴有远端血管对比剂滞留 dissections appear as new, persistent filling defects within the

coronary lumen. Type F 管腔充盈缺损,伴有管腔完全闭塞 dissections represent those

that lead to total occlusion of the coronary lumen without distal antegrade flow.

Page 6: Right Coronary Artery Dissection Caused by Catheter: a Case Report Xiaozeng Wang Haiwei Liu and Yaling Han Department of Cardiology, Shenyang Northern

• NHLBI classification system for coronary artery dissection types.

• Types A and B are generally clinically benign,

• types C through F portend significant morbidity and mortality if untreated.

Page 7: Right Coronary Artery Dissection Caused by Catheter: a Case Report Xiaozeng Wang Haiwei Liu and Yaling Han Department of Cardiology, Shenyang Northern
Page 8: Right Coronary Artery Dissection Caused by Catheter: a Case Report Xiaozeng Wang Haiwei Liu and Yaling Han Department of Cardiology, Shenyang Northern

Strategy

Spiral dissection of the right coronary artery from the proximal to the distal part of the vessel, it is a NHLBI type D dissection, so select PCI with deployment stent

had no angina and hemodynamic instability, no need for IABP implantation and emergency CABG.

Page 9: Right Coronary Artery Dissection Caused by Catheter: a Case Report Xiaozeng Wang Haiwei Liu and Yaling Han Department of Cardiology, Shenyang Northern

JR3.5, BMW 导丝, RCA 近段置入 Excel 4.0x18mm 支架

PCI for RCA JR3.5, BMW guide wire , Stent Excel 4.0x18mm was implanted

in the proximal part of the RCA

Page 10: Right Coronary Artery Dissection Caused by Catheter: a Case Report Xiaozeng Wang Haiwei Liu and Yaling Han Department of Cardiology, Shenyang Northern

RCA 近中段再次置入 Excel 4.0x24mm 支架,与前一支架重叠 2mm

PCI for RCA The second stent Excel 4.0x24mm was implanted in the p-m RCA. Two

stents were overlapped with 2mm

Page 11: Right Coronary Artery Dissection Caused by Catheter: a Case Report Xiaozeng Wang Haiwei Liu and Yaling Han Department of Cardiology, Shenyang Northern

RCA 远段夹层处置入 Accrua 3.0x20mm 支架 ;RCA 远段可见血栓影像,单纯支架囊扩张消失

PCI for RCA Stent Accrua 3.0x20mm was implanted in the distal part of RCA; Thrombus

image was found in the distal part of the RCA, and disappeared with the stent balloon dilatation

Page 12: Right Coronary Artery Dissection Caused by Catheter: a Case Report Xiaozeng Wang Haiwei Liu and Yaling Han Department of Cardiology, Shenyang Northern

RCA 中段置入 Accrua3.5x20mm 支架,与远段支架不相连,并支架内整形,最终造影结果满意。

Stent Accrua3.5x20mm was implanted in the m RCA. It was not linked with the distal stent. The final angiogram was excellent.

Page 13: Right Coronary Artery Dissection Caused by Catheter: a Case Report Xiaozeng Wang Haiwei Liu and Yaling Han Department of Cardiology, Shenyang Northern

Final angiography at the end of the procedure

PCI for RCA

Page 14: Right Coronary Artery Dissection Caused by Catheter: a Case Report Xiaozeng Wang Haiwei Liu and Yaling Han Department of Cardiology, Shenyang Northern

Follow-up Double oral anti-platelet therapy for eight months

(clopidogrel 75mg plus aspirin 100mg once daily)

Follow-up Coronary Angiography (Oct 20, 2009) : No restenosis was found in RCA, TIMI grade 3 flow

Current oral medical therapy: aspirin 100 mg once

daily, antihypertensive medical and atorvastatin

There was absence of angina, and a normal ECG

was detected

Page 15: Right Coronary Artery Dissection Caused by Catheter: a Case Report Xiaozeng Wang Haiwei Liu and Yaling Han Department of Cardiology, Shenyang Northern

Coronary AngiographyOct 20, 2009

No restenosis was found in RCA

Page 16: Right Coronary Artery Dissection Caused by Catheter: a Case Report Xiaozeng Wang Haiwei Liu and Yaling Han Department of Cardiology, Shenyang Northern

Atherosclerosis changes in LCA

Coronary AngiographyOct 20, 2009

Page 17: Right Coronary Artery Dissection Caused by Catheter: a Case Report Xiaozeng Wang Haiwei Liu and Yaling Han Department of Cardiology, Shenyang Northern

Lessons and comprehends

Catheter-induced coronary dissection

can be formed in “normal” look liked

coronary artery

Stent implantation should be from the

distal to the proximal of the dissection

Page 18: Right Coronary Artery Dissection Caused by Catheter: a Case Report Xiaozeng Wang Haiwei Liu and Yaling Han Department of Cardiology, Shenyang Northern