Case presentation

An active 60-year-old man with a history of tobacco abuse, prostate cancer, hypertension, and several prior myocardial infarctions in the remote past presented with chest pain. He underwent coronary bypass surgery 16 years earlier consisting of a left internal mammary graft to the left anterior descending artery (LAD). He was in his usual state of health until midnight prior to admission when he awoke with severe substernal chest pain radiating to both shoulders and accompanied by dyspnea and diaphoresis. Sublingual nitroglycerin tablets alleviated the pain temporarily, only for it to recur. He drove himself to the emergency department at 5:00 am, where he was noted to have ST-segment depressions in the anterolateral leads on his ECG; the first troponin was negative. He was admitted and treated with unfractionated heparin, aspirin, clopidogrel, nitroglycerin, and a beta blocker and became pain-free. He was referred for catheterization the next day.

Cardiac catheterization

The left internal mammary graft to the LAD was intact and the LAD supplied collaterals to the circumflex (Video 37-1). The native LAD and circumflex were both occluded. Heavy calcification affected the right coronary artery and severe disease was present in the midsegment of this artery (Figures 37-1, 37-2 and Videos 37-2, 37-3). Because of extensive calcification, rotational atherectomy was planned. This was performed with a 1.5 mm burr through an 8 French right Judkins guide catheter after a temporary pacemaker was placed and procedural anticoagulation was achieved with unfractionated heparin and eptifibatide. Following rotational atherectomy, balloon angioplasty using a compliant, 2.5 mm diameter by 20 mm long balloon was accomplished at several locations within the mid-right coronary, and full inflation of the balloon was noted at nominal inflation pressures (Figure 37-3). The angiogram obtained after rotational atherectomy and balloon angioplasty is shown in Figures 37-4 and 37-5 and Videos 37-4 and 37-5. While the left anterior oblique projections appeared acceptable, the right anterior oblique projection revealed a large dissection in the midsection.

FIGURE 37-1 This is the left anterior oblique projection of the right coronary angiogram showing a severe stenosis in the mid portion of the artery.

FIGURE 37-2 This is the right anterior oblique projection of the right coronary artery showing the severe stenosis of the midsegment of the right coronary artery and extensive calcification.

FIGURE 37-3 The balloon was fully expanded after performance of rotational atherectomy.

FIGURE 37-4 Angiographic appearance following rotational atherectomy and balloon angioplasty.

FIGURE 37-5 An extensive dissection is apparent in the right anterior oblique projection (arrow).

The operator then attempted to advance a stent (3.0 mm diameter by 20 mm long paclitaxel-eluting stent) to the mid-right coronary lesion with the goal of covering the entire dissection. However, the stent would not advance to the desired location. The operator decided to withdraw this stent and try a shorter, bare-metal stent; however, the first stent was firmly embedded in the lesion and would not withdraw to the guide. The operator feared that the stent might come off the balloon if additional force was applied and deployed the stent at the location, it became trapped (Figure 37-6). The angiogram obtained after this stent was deployed proximal to the desired location is shown in Figure 37-7. This stent was then aggressively postdilated with a noncompliant balloon and the unstented lesion in the midportion of the artery aggressively ballooned with a noncompliant balloon to high pressures after an additional and more supportive guidewire was placed as a “buddy” wire to facilitate another attempt at stent placement. The operator then chose a 3.0 mm diameter by 8 mm long bare-metal stent. With great difficulty, this stent was advanced distally, covering the distal part of the dissection (Figure 37-8