Balloon Uncrossable Left Main Coronary Artery Dissection: A Case Report and Literature Review
Syed Yaseen Naqvi1,2, Ahmed Qasim Alhaideri3, Ali Razzaq3
1Department of Internal Medicine, College of Medicine University of Warith Al-Anbiyaa Karbala Iraq.
Insights
Managing severe calcified coronary artery disease is challenging. This case demonstrates a novel technique to successfully cross a balloon-uncrossable lesion and treat a dissection during percutaneous coronary intervention.
Area of Science:
- Cardiology
- Interventional Cardiology
- Vascular Medicine
Background:
- Coronary artery dissection is a high-risk complication during percutaneous coronary intervention (PCI).
- Severe calcification significantly increases the complexity and risk of PCI, often leading to undilatable or uncrossable lesions.
- Left main coronary artery (LMCA) involvement adds further complexity and risk.
Purpose of the Study:
- To report a novel strategy for managing a balloon-uncrossable, calcified lesion in the left anterior descending (LAD) artery extending into the LMCA.
- To describe the successful treatment of a large LMCA-to-LAD dissection flap that occurred during PCI.
- To highlight the importance of innovative approaches and multidisciplinary collaboration in complex coronary interventions.
Main Methods:
- Percutaneous coronary intervention (PCI) was performed for a calcified ostial-to-mid LAD lesion extending into the LMCA.
- Initial attempts at balloon pre-dilatation were successful, but a drug-eluting stent (DES) could not cross the lesion.
- A novel technique involving forceful advancement of a small semi-compliant balloon (1.0 mm) during deflation was used to cross the lesion.
- Lesion preparation, overlapping DES deployment, and post-dilatation were performed.
Main Results:
- The novel balloon technique successfully enabled device passage across the previously uncrossable calcified lesion.
- A large LMCA-to-LAD dissection flap was successfully managed.
- Overlapping drug-eluting stents were deployed, and post-dilatation resulted in excellent angiographic outcomes.
- The patient remained hemodynamically stable throughout the procedure.
Conclusions:
- Complex calcified coronary lesions, especially those extending into the LMCA, pose significant PCI challenges.
- Innovative techniques, such as using a small semi-compliant balloon during deflation, can overcome device uncrossability.
- Prompt recognition and management of procedural complications like dissection, coupled with multidisciplinary teamwork, are crucial for successful outcomes in interventional cardiology.
Abstract:
Coronary artery dissection presents a high-risk scenario, particularly when complicated by severe calcification. We report a complex case of a balloon-uncrossable lesion encountered during percutaneous coronary intervention (PCI) of a calcified ostial-to-mid left anterior descending (LAD) artery lesion extending into the LMCA. A 54-year-old male with type 2 diabetes and exertional angina underwent coronary angiography revealing severe calcified LAD disease. Despite successful initial balloon pre-dilatation, a drug-eluting stent (DES) could not cross the lesion. Withdrawal attempts resulted in a large LMCA-to-LAD dissection flap, preventing further device passage. Urgent multidisciplinary consultation was initiated. A novel approach using forceful advancement of a 1.0 mm semi-compliant balloon during deflation enabled successful lesion crossing. This was followed by lesion preparation, overlapping DES deployment, and optimized post-dilatation. The patient remained stable, with excellent angiographic results. This case underscores the importance of innovation and teamwork in managing complex, calcified coronary lesions with unexpected procedural complications.
