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Case Report
A Novel Use of Cutting Balloon in Treating Coronary Artery Dissection that Developed During Percutaneous Coronary Intervention
April 2003
Key words: acute occlusion, bail-out, coronary angiography, coronary stent
Coronary dissections sometimes compromise distal flow due to lack of re-entry, or compression by hematoma after wire manipulation or balloon dilatation during percutaneous coronary intervention (PCI). Although such dissections might be managed successfully with stent implantation,1,2 in cases in which the dissection is excessively long, another option is to restore antegrade flow in the true lumen by creating re-entry to the dissection before the decision to deploy stents. Due to its unique structure, the Cutting Balloon (CB) (Interventional Technologies, San Diego, California)3 has been utilized in various clinical settings4–7 other than dilatation of de novo coronary stenosis8 or in-stent restenosis.9 This report represents another niche of the CB in coronary intervention by presenting 2 cases.
Case Report
Patient #1. A 62-year-old man with non-insulin dependent diabetes mellitus visited our hospital to undergo detailed examination of angina pectoris. He had experienced chest pain on effort, such as during bicycle riding, since 10 days before examination. Coronary angiogram performed 3 years prior had revealed chronic total occlusion (CTO) with bridge collaterals in the proximal right coronary artery (RCA) and intermediate stenosis in the left circumflex coronary artery (LCX). PCI was performed for progression of LCX lesions with balloon angioplasty and stenting and for CTO of the RCA (unsuccessful) on March 2, 2001. The patient experienced recurrence of chest pain and a repeat PCI procedure for CTO of the proximal RCA (Figure 1) was performed on August 29, 2001 following PCI for restenosis of the LCX lesions. Both Neo’s Miracle 3 gram and Conquest guidewires failed to cross the occlusion. The combined use of 2 Neo’s Conquest guidewires was also inadequate for recrossing the CTO. The subsequent use of balloon catheter back-up with a 1.5 x 20 mm Maverick balloon catheter (Boston Scientific/Scimed, Inc., Maple Grove, Minnesota) for one Conquest guidewire allowed the operator to cross the occlusion. Even after inflations with this balloon in the occluded region, only minimal antegrade flow was obtained (Figure 2). Intravascular ultrasound (IVUS) revealed that a large false lumen with hematoma had developed due to wire manipulation and compressed the true lumen (Figure 3). This hematoma could be detected by angiogram as a region of pooled contrast medium (Figure 2). At this time, the decision was made to create re-entry of the false lumen using a CB. A 3.0 x 10 mm CB was inflated several times, increasing inflation pressure maximally to 10 atmospheres (atm) around the distal end of the false lumen (Figure 4). After this procedure, antegrade Thrombolysis in Myocardial Infarction (TIMI) flow grade 3 was restored, but with the development of type C dissections according to the National Heart, Lung, and Blood Institute (NHLBI) classification (Figure 5). On IVUS imaging (Figure 6), an intimal tear that could have been created by the CB distal to the distal end of the false lumen was detected at the site opposite to the end of the false lumen, and collapse of the true lumen was resolved by communication between the true and false lumens. Since a wide false lumen existed even after cutting flaps, we deployed two 4.0 x 31 mm Radius stents (Boston Scientific/Scimed, Inc.), which fully covered the previously occluded region and dissections, resulting in excellent dilatations as recognized by both angiogram and IVUS (Figure 7). The first stent was deployed in a distal vessel to cover both entry and re-entry of the dissection. The second was implanted in the previously occluded segment before PCI. Post-stent dilatation was performed using a 4.5 x 20 mm Maxxum balloon catheter at 6 atm. A self-expandable Radius stent was considered suitable for this lesion because the lesion seemed compliant without severe calcification.
Patient #2. A 77-year-old man with hypertension and non-insulin dependent diabetes mellitus had a 5-year history of anterior chest oppression on exertion and underwent coronary angiography on January 21, 2001, which revealed 90% stenosis of the LCX (Figure 7) and 75% stenosis of the LAD by visual estimation. He underwent PCI for the LCX lesion, which was judged to be a culprit lesion for ischemia, 10 days after coronary angiography. A 3.0 x 13 mm Coroflex stent (B/Brown, Germany) was deployed after predilatation with a 3.0 x 20 mm Runner balloon catheter (Goodman, Aichi, Japan), and a type C dissection (NHLBI classification) occurred in the segment distal to the deployed stent. Thus, a 2.5 x 12 mm Nir/Elite stent (Boston Scientific/Scimed, Inc.) was inserted to cover the dissection. However, distal hematoma developed after the second stent, narrowing the true lumen (Figure 8). IVUS examination clearly showed compromise of the true lumen by hematoma (Figure 8). It was our strategy to use a CB to create re-entry to this dissection. The size of the CB was determined by IVUS imaging according to the vessel-to-vessel diameter at the site of the hematoma. After several inflations at 2–3 atm in the distal portion and at 6 atm in the proximal portion of the dissected segment, adequate antegrade flow was restored by creating re-entry. Coronary angiograms and IVUS imaging revealed blood flow in both the true and false lumens (Figure 9).
Discussion
In these 2 cases, flow-limiting coronary dissection or hematoma was successfully bailed out using CB angioplasty during PCI. During the PCI for CTO, the guidewire often proceeds into a false lumen. In this situation, or for coronary spiral dissections that could cause coronary occlusion with a large false lumen, the new method presented in this report would be very beneficial. Use of stents1,2 has dramatically improved our ability to treat these undesirable events, especially in hemodynamically unstable patients or in patients with severe ischemia. A sizable body of published literature suggests that the intracoronary stent is the most effective modality for the management of established or threatened abrupt closure. However, in patient #1, restoration of distal flow by CB enabled us to avoid extension of the dissection to the distal segment and to determine the exact location for optimal coronary stent deployment. In patient #2, bail-out with the CB was very beneficial because the reference diameter was too small for stent deployment in terms of long-term patency. Usually, it is difficult to cut an intimal flap to produce communication between the true and false lumens. Although pulling an inflated balloon10 has been previously attempted, it would be more invasive than our method and causes awkward rather than therapeutic dissections. A CB can incise intimal flaps without over-dilatation of the vessel and at lower inflation pressure due to the action of 3 or 4 blades on the CB.3
Long inflation with an autoperfusion balloon has had considerable success in treating coronary dissections and abrupt closure.11,12 Even if the autoperfusion balloon catheter does not yield a definitive result, it allows rapid restoration of antegrade flow prior to coronary stent placement. However, it might take more time than CB angioplasty and might be ineffective in creating re-entry. It also has several limitations, such as its dependence on adequate systemic blood pressure for passive blood flow, its relative stiffness and large deflated profile, and its susceptibility to thrombosis within the catheter lumen.
CB angioplasty is a very simple and quick method, although care must be taken to avoid the potential complications. It may cause coronary perfusion and extension of the dissection. Determination of an optimal-size CB is a very important issue when using this technique. Although over-sizing of the CB must be avoided to prevent perforation, vessel-to-vessel diameter at the cutting site determined by IVUS is considered ideal. Gradual increase in inflation pressure could make the procedure safe and avoid coronary perforation.
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