Inadvertent Percutaneous Coronary Endarterectomy Assessed by Multiple Imaging Modalities

J INVASIVE CARDIOL 2020;32(8):E221-E222. 

Key words: angiography, cardiac imaging, optical coherence tomography

An 82-year-old woman with a history of hypertension and dyslipidemia presented to our clinic complaining of chest and left shoulder pain. Coronary angiography revealed a 75% stenosis of the proximal left anterior descending artery (LAD) and a 90% stenosis of the diagonal branch (Figure 1A). Coronary computed tomography angiography (CTA) showed calcified plaque in the LAD and diagonal branch (Figure 1E). We proceeded with percutaneous coronary intervention (PCI) to a diagonal branch. During the procedure, a 0.014˝ Runthrough ultra floppy guidewire (Terumo) was entrapped in a heavily calcified lesion and difficult to remove. After extraction of the guidewire by force, the mid LAD was occluded and intravascular ultrasound (IVUS) in the proximal LAD revealed a remnant of endarterected tissue from a diagonal branch (Figure 1G). A drug-eluting stent (DES) was successfully implanted in the proximal to mid LAD. Final angiogram showed a dilated diagonal branch without ballooning or stenting (Figure 1B). Three months later, repeat coronary CTA showed a stenosis of the diagonal branch without calcification, which existed before the first PCI (Figure 1F). We then proceeded with a second PCI to a diagonal branch. Optical coherence tomography (OCT) showed homogenously signal-rich plaque without three-layered appearance in the lesion of a diagonal branch (Figure 1H). After dilation with a 2.0 x 15 mm Ikazuchi Zero balloon (Kaneka), final CAG showed a successfully dilated lesion (Figure 1D).

Coronary endarterectomy is a surgical option for a diffusely diseased coronary artery; however, it is not a technically simple procedure. Unfortunately, our inadvertent percutaneous coronary endarterectomy case resulted in early restenosis.

From the ¹Department of Cardiology, Tenyoukai Central Hospital, Kagoshima, Japan; and the ²Department of Cardiovascular Medicine and Hypertension, Kagoshima University, Kagoshima, Japan.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

The authors report that patient consent was provided for publication of the images used herein.

Manuscript accepted December 3, 2019.

Address for correspondence: Takashi Kajiya, MD, FACC, Department of Cardiology, Tenyoukai Central Hospital, Izumi-cho 6-7, Kagoshima-city, 892-0822, Japan. Email: t_kajiya@hotmail.com