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• W2166957504 abstract "Iatrogenic left main coronary artery (LMCA) dissection is an infrequent but potentially feared complication of cardiac catheterization [1Devlin G. Lazzam L. Schwartz L. Mortality related to diagnostic cardiac catheterization. The importance of left main coronary disease and catheter induced trauma.Int J Card Imaging. 1997; 13: 379-384Crossref PubMed Scopus (34) Google Scholar, 2Lee S.W. Hong M.K. Kim Y.H. Park J.H. Rhee K.S. Lee C.W. Han K.H. Song J.M. Kang D.H. Song J.K. Kim J.J. Park S.W. Park S.J. Bail-out stenting for left main coronary artery dissection during catheter-based procedure: acute and long-term results.Clin Cardiol. 2004; 27: 393-395Crossref PubMed Scopus (33) Google Scholar, 3Awadalla H. Sabet S. El Sebaie A. Rosales O. Smalling R. Catheter-induced left main dissection incidence, predisposition and therapeutic strategies experience from two sides of the hemisphere.J Invasive Cardiol. 2005; 17: 233-236PubMed Google Scholar]. It is twice as likely to occur during percutaneous coronary intervention (PCI) (0.10%) when compared to diagnostic catheterization (0.06%) [4Eshtehardi P. Adorjan P. Togni M. Tevaearai H. Vogel R. Seiler C. Meier B. Windecker S. Carrel T. Wenaweser P. Cook S. Iatrogenic left main coronary artery dissection: incidence, classification, management, and long-term follow-up.Am Heart J. 2010; 159: 1147-1153Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar]. This life-threatening complication is typically caused by vigorous hand injection of contrast medium, subintimal passage of guidewire, or inadvertent guiding catheter manipulation. The development of intimal tears and propagation of hematoma may be related to an underlying structural weakness of media. Although emergent coronary artery bypass graft surgery (CABG) is the most frequent therapeutic strategy to prevent deteriorating hemodynamic condition and worsening angina, the 30-day mortality rate remains as high as 26% following a successful CABG [5Kovac J.D. de Bono D.P. Cardiac catheter complications related to left main stem disease.Heart. 1996; 76: 76-78Crossref PubMed Scopus (22) Google Scholar]. It is a time-consuming procedure that carries the risk of irreversible and extensive myocardial damage. Prompt coronary stent implantation to bailout dissection is a useful option when managing this fatal complication. To cover intracoronary dissection with stents may seal the entry port of LMCA dissection. Intra-aortic balloon pump (IABP) may serve as a hemodynamic support during PCI, but is contraindicated in the presence of concomitant aortic dissection. Percutaneous cardiopulmonary support may be a crucial alternative [6Cheng C.I. Wu C.J. Hsieh Y.K. Chen Y.H. Chen C.J. Chen S.M. Yang C.H. Hung W.C. Yip H.K. Chen M.C. Fu M. Fang C.Y. Percutaneous coronary intervention for iatrogenic left main coronary artery dissection.Int J Cardiol. 2008; 126: 177-182Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar]. Kuriyama et al. reported a case of intravascular ultrasound (IVUS)-guided bailout for iatrogenic LMCA dissection [7Kuriyama N. Kobayashi Y. Shibata Y. Intravascular ultrasound-guided bailout for left main dissection.J Cardiol Cases. 2012; 5: e137-e139Abstract Full Text Full Text PDF Scopus (3) Google Scholar]. IVUS information was very useful to achieve a guidewire entering into the true lumen in the most perilous complication during PCI. IVUS is a powerful tool in this clinical scenario and ideally should be available with operators trained in its use. Furthermore, IVUS imaging may help to evaluate complete coverage of LMCA dissection, which presumably will prevent further propagation [8Goldstein J.A. Casserly I.P. Katsiyiannis W.T. Lasala J.M. Taniuchi M. Aortocoronary dissection complicating a percutaneous coronary intervention.J Invasive Cardiol. 2003; 15: 89-92PubMed Google Scholar]. This case illustrates the superiority of the images and information obtained with IVUS, which allows the examination of the true lumen, providing valuable information that can guide and prompt appropriate PCI procedures. The clinical utility of IVUS is a patent fact. The major use of IVUS is to plan PCI strategy and optimize stent deployment [9McDaniel M.C. Eshtehardi P. Sawaya F.J. Douglas Jr., J.S. Samady H. Contemporary clinical applications of coronary intravascular ultrasound.JACC Cardiovasc Interv. 2011; 4: 1155-1167Abstract Full Text Full Text PDF PubMed Scopus (94) Google Scholar]. Pre-PCI IVUS accurately assesses lesion length and reference lumen dimensions for appropriate stent sizing. Identification of superficial calcium can lead to pre-stent rotational atherectomy. Post-stent IVUS assessment may detect complications of PCI and suboptimal stent deployment. The benefit of IVUS-guided PCI is most important in complex lesion subsets, such as LMCA [10Park S.J. Kim Y.H. Park D.W. Lee S.W. Kim W.J. Suh J. Yun S.C. Lee C.W. Hong M.K. Lee J.H. Park S.W. Impact of intravascular ultrasound guidance on long-term mortality in stenting for unprotected left main coronary artery stenosis.Circ Cardiovasc Interv. 2009; 2: 167-177Crossref PubMed Scopus (418) Google Scholar] and bifurcation lesions [11Kim S.H. Kim Y.H. Kang S.J. Park D.W. Lee S.W. Lee C.W. Hong M.K. Cheong S.S. Kim J.J. Park S.W. Park S.J. Long-term outcomes of intravascular ultrasound-guided stenting in coronary bifurcation lesions.Am J Cardiol. 2010; 106: 612-618Abstract Full Text Full Text PDF PubMed Scopus (58) Google Scholar], where studies suggest that IVUS guidance may reduce mortality. It has been postulated that the mechanism of benefit is related to reduced rates of sudden cardiac death related to late stent thrombosis. In addition, IVUS is useful to assess intermediate coronary artery disease, especially in LMCA. IVUS can also provide insights into the mechanism of stent restenosis. Furthermore, IVUS can detect the development of transplant vasculopathy. These are supported by the American College of Cardiology/American Heart Association PCI guidelines (IIa or IIb indication) (Table 1) [12Levine G.N. Bates E.R. Blankenship J.C. Bailey S.R. Bittl J.A. Cercek B. Chambers C.E. Ellis S.G. Guyton R.A. Hollenberg S.M. Khot U.N. Lange R.A. Mauri L. Mehran R. Moussa I.D. et al.ACCF/AHA/SCAI guideline for percutaneous coronary intervention: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines and the Society for Cardiovascular Angiography and Interventions.Circulation. 2011; 124: e574-e651Crossref PubMed Scopus (1312) Google Scholar]. Perivascular IVUS landmarks such as coronary veins, pericardium, myocardium, and side branches are useful to know coronary artery geometry during PCI. In chronic total occlusion lesions, antegrade recanalization approaches often result in subintimal guidewire tracking. IVUS imaging from the false lumen may be useful to guide re-entry of the guidewire into the true lumen. In this case, both aorta and the guidewire in the false lumen were important landmarks to determine the orientation of the entry site of the false lumen of the LMCA dissection. Operators should be trained in its usage and be familiar with precise interpretation of IVUS images.Table 1Indication for intravascular ultrasound.Adapted from 2011 ACC/AHA/SCAI PCI guideline 12Levine G.N. Bates E.R. Blankenship J.C. Bailey S.R. Bittl J.A. Cercek B. Chambers C.E. Ellis S.G. Guyton R.A. Hollenberg S.M. Khot U.N. Lange R.A. Mauri L. Mehran R. Moussa I.D. et al.ACCF/AHA/SCAI guideline for percutaneous coronary intervention: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines and the Society for Cardiovascular Angiography and Interventions.Circulation. 2011; 124: e574-e651Crossref PubMed Scopus (1312) Google Scholar.Class IIaAssessment of angiographically indeterminant left main coronary artery disease (level of evidence: B)Assessment of cardiac transplant vasculopathy (level of evidence: B)Determine the mechanism of stent restenosis (level of evidence: C)Class IIbAssessment of non-left main coronary arteries with angiographically intermediate coronary stenosis (50–70% diameter stenosis) (level of evidence: B)Guidance of coronary stent implantation, particularly in cases of left main coronary artery stenting (level of evidence: B)Determine the mechanism of stent thrombosis (level of evidence: C)Class IIIRoutine lesion assessment when revascularization with PCI or CABG is not being contemplated (level of evidence: C)PCI, percutaneous coronary intervention; CABG, coronary artery bypass graft. Open table in a new tab PCI, percutaneous coronary intervention; CABG, coronary artery bypass graft. Intravascular ultrasound-guided bailout for left main dissectionJournal of Cardiology CasesVol. 5Issue 3PreviewThis case report demonstrates iatrogenic left main coronary artery dissection during percutaneous coronary intervention. Intravascular ultrasound imaging showed that the entry site of the false lumen was located at the cranial part of the ostium of the left main coronary artery. Utilizing this information, the operator was able to achieve the guidewire entering into the true lumen. Full-Text PDF Open Archive" @default.
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• W2166957504 title "Defining a role of intravascular ultrasound in percutaneous coronary intervention" @default.
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