Abstract Corner: Nightmare in Normal Coronaries

The purpose of this new Abstract Corner is an easy one to explain. In a nutshell, over the years, we have seen many excellent abstracts submitted at various scientific sessions. These sessions are nation/international, and reach interventional and invasive participants.

Most symposiums call for researchers to submit their abstract for review by the committees tasked with that job. The criteria are clear: it must be pertinent, well done, have basic abstract format for printing, and if accepted, usually there are perks for the author of the abstract.

The perks vary from waived admission fees to faculty status at the symposium. Many authors submit and there is a finite number accepted. There are many abstracts that are well done, but just not enough time and money to accept everyone.

Hence our thought ­— would there be interest from Cath Lab Digest to publish these other abstracts?  Would there be an interest from the authors to share their papers with our readers? The Abstract Corner will solicit abstracts from the poster sessions at various conferences that will not be otherwise published.

I first approached Dr. Rajesh Dave, the Director of the Complex Cardiovascular Catheter Therapeutics (C3) conference each June, and he thought it would be a good idea to give these authors a medium to share their abstracts in a manner that reaches thousands of readers each month. Dr. Dave is well known for his dedication and support for staff and physicians alike, and his C3 conference had many wonderful abstracts presented this year.  

Working with Rebecca Kapur, Managing Editor of CLD, we now present the first of what we hope will be many abstracts for your reading pleasure.  

               — Marsha Holton, CCRN, RCIS, FSICP

Do you have a conference abstract to share with readers? Email Marsha Holton, CCRN, RCIS, FSICP, at marshasicp@aol.com.

Nightmare in Normal Coronaries

Introduction

Iatrogenic coronary artery dissection during diagnostic coronary catheterization is a rare but life-threatening event.1 It results from mechanical injury to the arterial wall during catheter or wire manipulation, passage of an interventional device, forceful injection of contrast medium, balloon dilatation, or stenting.1 Patients with ostial coronary artery stenosis, hypertension, Marfan syndrome, congenitally unicuspid and bicuspid aortic valves, reported to be at higher risk of dissection. 

In normal coronaries, is there a risk for dissection? Should a dissection occur, what are the complications and what should be done?

Case Presentation

A female patient, 55 years old, not hypertensive, and not diabetic, presented to our clinic with repetitive episodes of shortness of breath and chest pain. To some extent, the pain was exertional and in same location, and was relieved with rest. Resting electrocardiogram showed nonspecific changes. Resting echo was normal. A dobutamine stress echo was positive.

Decision-making was in favor of coronary angiography, as other diagnostic modalities such as computed tomography angiography (CTA), were not available in our locality. A femoral approach was chosen (no available radial sets). The left coronary system was cannulated by a Judkins left (JL)4, 6 French (Fr) catheter. No lesions were visualized. The right coronary artery (RCA) was cannulated by a Judkins right (JR) 3.5, 6 Fr catheter. There was no forceful manipulation of the catheter and an easy cannulation was performed.

Catheter-induced dissection of the proximal RCA was accidentally committed, and trials of non-selective cannulation were done and revealed no ostial lesions. The patient suddenly complained of severe chest pain. There was ST-segment elevation in the inferior leads. Rapid measures were prepared to fix the dissection before it spread retrograde into the ascending aorta, including 10,000 units of unfractionated heparin and use of a JR4, 6 Fr guide catheter, through which a PT LS (light support) (Boston Scientific) wire was successfully crossed to the distal end of the RCA. The inlet segment was fixed by a Suna 3.5 x 28 mm bare-metal stent (Tsunamed) deployed at 14 atmospheres (atm), while the exit was fixed by a second Suna 3 x 34 mm bare-metal stent deployed at 12 atm. The patient arrested on ventricular fibrillation (VF) and received a direct-current (DC) shock. A third Coroflex 2.75 x 24 mm stent (B. Braun) was deployed at 14 atm.

The patient’s chest pain was resolved and hemodynamics changes improved. The patient was transferred to the coronary care unit and was discharged on the third day after improvement.

Discussion

Diagnostic coronary angiography is simple, but not without complications, and may end up a nightmare. Always expect and be prepared for any complications. Avoid deep engagement of the catheter and check the pressure waveform before every coronary injection. Coronary dissection in diagnostic normal coronaries is a rare but potentially life-threatening complication. Be calm, and act rapidly and wisely.

Reference

1. Shafey WEDH. Catheter-induced dissection of a normal right coronary artery: Reappraisal of the underlying mechanisms. The Egyptian Heart Journal. 2016 June; 68(2): 137-139.

Note from author Violet Andrawes, FEBIC: Acknowledgments to my professor Dr. Mohammad Ghareeb, head of the Cardiac Catheterization Department of Nasr City Insurance Hospital, and Professors Dr. Adel Eletrby and Dr. Ahmad Magdy, who are my trainers in the intervention fellowship, for their great support.