Case presentation

A 63-year-old woman with hypertension, tobacco abuse, and dyslipidemia, but no prior coronary events, developed stable angina pectoris. Her physician evaluated these symptoms with an exercise stress test. During the stress test, chest discomfort began at a low workload and the scintigraphic images revealed reversible perfusion defects in multiple zones, including the inferior and anterior walls and the apex. She was referred for an elective cardiac catheterization.

Cardiac catheterization

Diagnostic catheterization found normal left ventricular function and significant stenoses in the proximal segment of the right coronary artery (Figure 19-1 and Video 19-1) and in the left anterior descending artery (Figures 19-2, 19-3 and Video 19-2). The left circumflex artery appeared angiographically normal. Coronary calcification was noted in both the right coronary and left anterior descending arteries. After discussing the options of medical therapy, coronary bypass surgery, and percutaneous coronary intervention, the patient chose a percutaneous revascularization strategy.

FIGURE 19-1 This is a left anterior oblique projection of the right coronary artery demonstrating the severe stenosis in the proximal segment. An Amplatz guide catheter was used to acquire this image (arrow).

FIGURE 19-2 This angiogram of the left coronary artery in a right anterior oblique projection with caudal angulation depicts the severe stenosis of the left anterior descending coronary artery after a first septal perforator (arrow). The circumflex is free of angiographic disease.

FIGURE 19-3 Angiography of the left coronary artery in the right anterior oblique projection with cranial angulation, demonstrating the lesion in the left anterior descending artery (arrow).

After administration of a bolus of 70 U/kg of unfractionated heparin followed by a double bolus and infusion of eptifibatide, the operator first approached the left anterior descending artery. The lesion was first dilated with a balloon and then treated with a sirolimus-eluting stent (Figure 19-4). The operator then turned attention to the right coronary artery. Anticipating the need for extra backup to support the intervention, due to the presence of coronary calcification noted on the diagnostic study, the operator chose a left Amplatz guide catheter (AL-2), as shown in Video 19-1. Although this guide catheter appeared to provide excellent support, pressure damping and retention of contrast in the arterial wall was observed in the proximal segment consistent with a guide-related dissection, leading to the exchange of the Amplatz guide for a right Judkins guide catheter. Upon engagement, the physician noted distal extension of the dissection, with retention of contrast nearly to the bifurcation of the posterior descending and posterolateral branches (Figure 19-5