PMC4631865_01
(a) Left anterior oblique (LAO) projection showing a favourable angiographic appearance of the RCA. (b) Right anterior oblique (RAO) cranial projection showing a long tubular stenosis of the mid-LAD, with abrupt demarcation (**) from normal proximal segments (*), which did not respond to intracoronary nitroglycerine. (c) IVUS examination showed near-circumferential hematoma (H) extending deep into the media and reducing the lumen (L). No atheroma was visualised. (d) IVUS examination of the proximal segments revealed normal vessel appearance and preserved lumen (L) caliber. (e) Final angiographic appearance of the mid-LAD, in RAO cranial projection. (f-h) At 6-month follow-up, RAO cranial projection of mid-LAD showing good coronary flow but with still evidence of significant vessel dissection in its distal course.
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fig1
The coronary angiogram (CA) demonstrated the right coronary artery (RCA) dominant and normal (Figure 1(a)); the left main stem and circumflex vessels all appeared normal, but there was a very unusual appearance in the mid left anterior descendent (LAD), of an almost subtotally occluded long tubular segment of LAD disease after a large diagonal branch (Figure 1(b)) with TIMI 2 coronary flow, which did not respond to 200 micrograms of intracoronary nitroglycerine. However, there was a very long segment of about 70-80 mm in length of IH, which was compressing the true lumen (Figures 1(c) and 1(d)). After further predilatation with a 2.5/20 mm balloon at 10 atm and further 200 micrograms of intracoronary nitrate the flow picked up and the ST segments then settled and the patient became pain-free (Figure 1(e)). The area of interest has been partially normalised; however there was still evidence of a significant dissection in its distal course (Figures 1(f)-1(h)).
PMC4631865_02
(a, b) RAO cranial and spider projections showing normal left coronary system. (c, d) LAO and RAO projections showing a very long tubular stenosis of the RCA, with abrupt demarcation from normal distal segments, which did not respond to intracoronary nitroglycerine and balloon predilation. (e) After the implantation of the first ZES 2.75/30 mm, there was a propagation of the dissection flap proximally (white line; red arrow (f)), successfully sealed with a second ZES 3/30 mm implanted proximally (g). (h) Postdilation with the stent balloon at the overlap of the 2 stents and with noncompliant balloon 3.25 mm proximally at 16 atm (i-k) with an excellent final angiographic result (l).
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fig2
Urgent CA demonstrated an unobstructed left coronary system (Figures 2(a) and 2(b)) with an almost subtotally occluded long tubular abnormality within the RCA (Figures 2(c) and 2(d)), which did not respond to intracoronary nitroglycerine, with TIMI 2 flow. Primary PCI was successfully performed, with two zotarolimus eluting stents 2.75/30 mm and 3/30 mm implanted (distal to proximal) (Figures 2(e)-2(h)) and postdilated with a 3.25 mm noncompliant balloon at 16 atm (Figures 2(i)-2(k)) with an excellent angiographic result (Figure 2(l)).