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A Phantom Lesion in the Left Main Coronary Artery: Concertina Effect
Abstract
J INVASIVE CARDIOL 2021;33(11):E919.
Key words: concertina effect, coronary dissection, guidewire, left main coronary artery
Case Presentation
A 64-year-old hypertensive woman presented with Canadian Cardiovascular Society (CCS) class II angina, 1 month post anterior-wall ST-segment elevation myocardial infarction (STEMI). She had previously received thrombolytic therapy at another hospital. Echocardiography showed hypokinesia in the left anterior descending (LAD) coronary artery territory with an ejection fraction of 40%. Coronary angiogram revealed significant stenosis in the proximal LAD, while other epicardial vessels were tortuous but essentially normal. Following informed consent, the treatment plan included coronary angioplasty with stenting for the LAD artery obstruction.
A Balanced Heavy Weight wire (Abbott Vascular) was used for crossing the LAD artery obstruction. We deployed a coronary stent (3.0 x 18 mm, Promus Element stent; Boston Scientific) in the proximal LAD, covering the lesion successfully. However, following stent deployment, we found an additional lesion in the left main coronary artery (Figure 1A and Video Series), which was persistent even after intracoronary nitroglycerin injection.
Catheter-induced dissection of the left main coronary artery was considered. Previous angiography views confirmed that the new lesion had appeared just after wiring the LAD artery. This indicated a possible concertina effect in the left main. The guidewire, following the stent placement, was cautiously removed, keeping the floppy portion in the left main for an easy repeat access if required. On withdrawal of the guidewire, the lesion in the left main disappeared completely (Figure 1B and Video Series).
Classically described in tortuous coronaries, the concertina effect is a type of pseudostenosis induced by guidewire and is extremely rare in the left main coronary artery because of its short length. However, concertina effect in the left main coronary artery after percutaneous intervention should be considered in the appropriate setting to avoid confounding management dilemmas and unwarranted interventions.
Affiliations and Disclosures
From the 1Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India; and 2Department of Cardiovascular Radiology and Endovascular Interventions, All India Institute of Medical Sciences, New Delhi, India.
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.
Manuscript accepted June 26, 2021.
The authors report patient consent for image used herein.
Address for correspondence: Dr Gautam Sharma, Professor, Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India 110029. Email: drgautamsharma12@gmail.com
