Background: A stent in a false lumen is a common cause of stent occlusion after coronary percutaneous coronary artery intervention therapy, particularly in the culprit lesion of acute myocardial infarction. Here, we present an unusual case of successful recanalization of the proximal right coronary artery with implementation of another stent to crush the previous stent in the false lumen. Case presentation: A 40-year-old Chinese man underwent coronary stent implementation in the proximal right coronary artery due to acute inferior wall myocardial infarction at another hospital. Six months later, he underwent coronary angiography re-examination for recurrent symptomatic angina at our hospital. Coronary angiography and intravascular ultrasound confirmed that the previous stent was deployed in the false lumen of the right coronary artery. Then, intravascular ultrasound was used to guide the wire to re-enter the true lumen of the proximal right coronary artery, and another stent was deployed into the true lumen to crush the previous stent. Conclusion: Intravascular ultrasound proved to be a pivotal tool in confirming false or true lumen, as well as determining favorable proximal site entry points to avoid rewiring the mesh of the previous stent. Keywords: Stent occlusion, False lumen, Intravascular ultrasound, Percutaneous coronary intervention Introduction proximal right coronary artery (RCA) and implemen- A stent in a false lumen is a common cause of stent tation of another stent to restore Thrombolysis In occlusion after coronary percutaneous coronary ar- Myocardial Infarction (TIMI) grade III coronary flow. tery intervention (PCI) therapy. In particular, in the In this case, the procedural details of how to open culprit lesion of acute myocardial infarction (AMI), it the false lumen, perform intravascular ultrasound is easier for the wire to go through the false or dissec- (IVUS)-guided wire into the true lumen, and avoid tion lumen . Repercutaneous intervention treat- rewiring the mesh of the previous stent, which ment, including wiring the true lumen and exclusion differed from other cases, were described in detail. stenting of the dissection flap, is usually performed. Detailed descriptions of techniques for guiding the Case presentation wireto re-enter thetruelumen with chronictotal A 40-year-old Chinese man had a history of occlusions have been published. Here, we present an ST-segment elevation inferior myocardial infarction 6 interesting case of successful intentional false lumen months earlier. He received primary PCI therapy at an- stenting with re-entry into the true lumen of the other hospital. Following predilation with a 2.0 × 20-mm balloon at 12 atm for 6 seconds, a 3.5 × 24 mm sirolimus-eluting stent (EXCEL, JW Medical Systems, * Correspondence: firstname.lastname@example.org Yabin Wang and Lei Gao contributed equally to this work. Shandong Province, China) was implanted in the Department of Cardiology & National Clinical Research Center for Geriatric lesions of the proximal RCA. However, after stent Diseases, Chinese PLA General Hospital, Beijing 100853, China 2 implantation, coronary angiography (CAG) showed Department of Cardiology, Chinese PLA General Hospital, Beijing 100853, China TIMI grade0flow in theRCA (Fig. 1). He did not © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Wang et al. Journal of Medical Case Reports (2018) 12:386 Page 2 of 4 Fig. 1 The primary percutaneous coronary artery intervention therapy for acute proximal right coronary artery occlusion in another hospital. a Angiography for right coronary artery. b Angiography after balloon predilation. c Stent implement in false lumen of proximal right coronary artery. d Final angiography receive further PCI therapy because he had no persist- A heart examination revealed no bulge, abnormal ent chest pain at that time. He was prescribed regular impulse, or thrills in precordial area. The border of his dual anti-platelet (PLT) therapy with aspirin and clopi- heart was normal, and the point of maximum impulse dogrel, as well as statin treatment. was in his fifth left intercostal space inside the mid cla- Six months later, he was admitted to our hospital for vicular line and it was not diffuse. There was no peri- recurrent unstable angina. He denied a history of cardial friction sound. His heart sounds were strong hypertension, diabetes mellitus, and valvular heart dis- and there was no splitting. His cardiac rhythm was ease. He also denied being allergic to pollen, dust med- regular with no pathological murmurs. ications, or food, and surgical procedures and injuries. A neurological examination showed normal abdom- He was married at the age of 23 years and he had one inal, bicipital muscular reflex, patellar and heel-tap boy and one girl. He received aspirin (0.1 g per day) reflex with Babinski sign (−), Oppenheim sign (−), and clopidogrel (75 mg per day) prior to admission. He Gordon sign (−), Chaddock sign (−), Hoffmann sign had smoked 20 cigarettes per day for 10 years, and had (−), Kernig sign (−), and Brudzinski sign (−). drunk a little amount of alcohol for 20 years. An electrocardiogram (ECG; 24 October 2017) in A physical examination showed: temperature (T) our hospital showed that deep Q waves were present 36.4 °C, pulse (P) 85/minute, respiratory rate (RR) 20/ in the II, III, and aVF leads, suggesting old lower minute, and blood pressure (BP) 130/80 mmHg. He wall myocardial infarction. An initial echocardio- was well developed, moderately nourished, and active. gram revealed a left ventricular ejection fraction His skin was not stained yellow, with no cyanosis, pig- (LVEF) of 41%. mentation, skin eruption, or spider angioma. There Laboratory findings (25 October 2017) in our hos- was no pitting edema. pital showed: red blood cells (RBC) 4.41 × 10 /L, Wang et al. Journal of Medical Case Reports (2018) 12:386 Page 3 of 4 white blood cells (WBC) 5.81 × 10 /L, N 71.9%, 12 mm balloon at 16–18 atm. Blood flow into the RCA hemoglobin (HGB) 133 g/L, PLT 225 × 10 /L, aspartate finally recovered to TIMI grade III (Fig. 2). Another 12 aminotransferase (AST) 10.5 U/L, alanine aminotrans- months of dual anti-PLT therapy was recommended to ferase (ALT) 11.7 U/L, creatinine (Cr) 7.2 mmol/L, and prevent stent thrombosis and restenosis. Our patient blood urea nitrogen (BUN) 102 umol/L. Cardiac bio- completed his 6-month and 9-month out-patient markers of troponin T (TnT), creatine kinase (CK), follow-up visits with no complaints of discomfort and isoenzyme of CK (CK-MB) were negative. (Table 1). A repeat CAG showed that although the proximal edge of the previous stent exhibited total occlusion, Discussion flow into the distal RCA through another pathway Stent restenosis or occlusion is a potentially life-threat- could be seen. The JR4.0 guide catheter was placed im- ening complication of PCI that may cause myocardial mediatelyoutside theostiumofthe RCA, andwead- infarction or heart failure. Here, we report a case of re- justed the direction of the guide wire to direct it from peat stent implementation to completely rescue occlu- theostialtruelumen into thedistalRCA.Then, IVUS sion of the RCA by crushing a previous stent in the was performed to confirm that the previously deployed false lumen . We also described the procedural steps stent was in the false lumen, resulting in stent occlu- of how to open the false lumen, perform IVUS-guided sion, and that this guide wire did not go through the wire into the true lumen, and how to avoid rewiring struts of the previous proximal stent [2, 3]. A balloon the mesh of the previous stent in detail, all these dif- (Sprinter 2.0 × 20 mm, Medtronic, Minneapolis, Min- fered from other literature. nesota, USA) was then predilated at 14–16 atm to There are several points we can learn from this crush the previous stent. Another 4.0 × 20 mm stent case. First, imaging results from angiography must be (BuMA™,SINOMED, Tianjin,China)was deployed in read carefully, and confirming thetruelumen before thetruelumen of theproximalRCA to crushthe pre- PCI is important. Repeat CAG revealed flow into the vious stent, followed by postdilation with a 4.0 × distal RCA from the ostial true lumen. Then, a JR4.0 Fig. 2 Coronary angiography and intravascular ultrasound. a Wire re-entry into true lumen of right coronary artery. b Coronary angiography revealed that the wire was in true lumen of right coronary artery. c Coronary angiography after true lumen stent implementation. d–f Intravascular ultrasound confirmed that wire was in the true lumen from distal, mid, and proximal right coronary artery respectively Wang et al. Journal of Medical Case Reports (2018) 12:386 Page 4 of 4 Table 1 Timeline data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. All authors read and approved the 14 April 2017 Chest pain, sweating, and vomiting final manuscript. 14 April 2017 The patient was admitted to a local hospital and received primary percutaneous coronary Ethics approval and consent to participate artery intervention therapy All human participants, human data or human tissue in this manuscript have obtained ethics committee approval and consent of Chinese PLA 21 April 2017 Discharged home to take dual anti-platelet general hospital. Informed consent to participate in the study has been and statin treatment obtained from the patient. 24 October 2017 The patient was admitted to Cardiology Consent for publication department of our hospital for recurrent Written informed consent was obtained from the patient for publication of unstable angina. this case report and any accompanying images. A copy of the written 24 October 2017 He received percutaneous coronary artery consent is available for review by the Editor-in-Chief of this journal. The intervention therapy for right coronary artery authors declare that we all agree to the submission of the final manuscript to Journal of Medical Case Reports. It is understood that upon acceptance for 30 October 2017 Discharged home. We recommended that publication the entire copyright in this manuscript shall pass to Journal of the patient take dual anti-platelet and statin Medical Case Reports. treatment for another 12 months. Competing interests guide catheter was placed outside the ostium to allow The authors declare that they have no competing interests. guidewireentryinto thetruelumen of the proximal RCA . IVUS proved to be a pivotal tool in con- Publisher’sNote Springer Nature remains neutral with regard to jurisdictional claims in published firming false or true lumen, as well as determining fa- maps and institutional affiliations. vorable proximal site entry points to avoid rewiring the mesh of the previous stent. Furthermore, there Received: 30 May 2018 Accepted: 26 October 2018 are some surgical points that should be considered to avoid wiring the false lumen. Contralateral angiog- References raphy, microcatheter angiography, and IVUS can be 1. Thomas BN, Aslam S, Cullen J, et al. Spontaneous coronary artery dissection in men presenting with acute coronary syndrome, successfully managed by performed to confirm whether the guide wire is in intravascular ultrasound-guided percutaneous coronary intervention. BMJ the true lumen. Physicians should not predilate le- Case Rep. 2014;2014 https://doi.org/10.1136/bcr-2013-009169. [published sions with a balloon or deploy a stent if they are un- Online First: 2014/04/11] 2. Kalra A, Aggarwal A, Kneeland R, et al. Percutaneous Coronary Intervention certain that the guide wire is in the true lumen. in Spontaneous Coronary Artery Dissection: Role of Intravascular Ultrasound. Physicians should also avoid aggressively engaging the Cardiol Ther. 2014;3(1–2):61–6. https://doi.org/10.1007/s40119-014-0029-4. ostium of the coronary artery with the guide catheter, 3. Mahmood MM, Austin D. IVUS and OCT guided primary percutaneous coronary intervention for spontaneous coronary artery dissection with and it is safer to place the guide catheter immediately bioresorbable vascular scaffolds. Cardiovasc Revasc Med. 2017;18(1):53–7. outside the ostium to avoid catheter-induced dissection. https://doi.org/10.1016/j.carrev.2016.09.005. 4. Omurlu K, Ozeke O. Side-by-side false and true lumen stenting for recanalization of the chronically occluded right coronary artery. Heart Conclusion Vessels. 2008;23(4):282–5. https://doi.org/10.1007/s00380-008-1052-y. IVUS proved to be a pivotal tool in confirming false [published Online First: 2008/07/24] 5. Wassef AW, Kirkpatrick I, Minhas K, et al. The double helix angiography of or true lumen, as well as determining favorable prox- right coronary arteries: false lumen stenting of a type F right coronary artery imal site entry points to avoid rewiring the mesh of spiral dissection with late recanalization of the true lumen and occlusion of the previous stent. the stented false lumen. Heart Int. 2014;9(1):26–9. [published Online First: 2014/01/01] Acknowledgements Not applicable. Funding This work was supported by the National Key Research Program of China (No2016YFA0100900), the National Nature Science Foundation of China (No 81500360, 81227901, 81530058and 81570272), China Postdoctoral Science Foundation (2016T90990 and 2016M603026), and Big Data Program of Chinese PLA general hospital (2017MBD-008). Availability of data and materials Authors of this manuscript make readily reproducible materials described in the manuscript, including new software, databases, and all relevant raw data, freely available to any scientist wishing to use them, without breaching. Authors’ contributions YBW and LG contributed to the writing of the first draft of the report and the initial discussion. YBW, LG, MZ, YDC, and FC were involved in the care and therapy of the patient. YBW and FC reviewed the manuscript. FC is the guarantor of this work and, as such, had full access to all the
Journal of Medical Case Reports – Springer Journals
Published: Dec 30, 2018
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