PMC5259594_01
The angiographic presentation of the course of the events. Images are captured at the right anterior oblique view. (a) The initial cardiac catheterization showing severe in-stent stenosis, quite tight at the proximal part of the stent involving the ostium of the diagonal branch. (b) Balloon expansion at high pressure failed to expand the lesion. (c) After balloon rupture, there was a massive type B coronary artery dissection starting at the distal part of balloon expansion (the radiolucent lines are highlighted with the arrow). (d) Rotational atherectomy was successfully performed with a 1.25 mm burr passing through the critical stenosis. (e) Successful balloon expansion after rotablation. (f) Excellent final result with TIMI III flow after stent deployment.
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The coronary angiography was performed through the right radial approach after placement of a 6 Fr radial sheath (KDL, China) and it showed one vessel disease with significant restenosis within the previously implanted stents (Figure 1(a)). We crossed the lesion using a workhorse guidewire (Luge, Boston Scientific) and dilatation was performed with a 2.0 mm semicompliant balloon (Sprinter Legend RX, Medtronic), but the lesion remained undilatable (Figure 1(b)). At the third attempt to expand the lesion using high pressure (at 22 Atm), the balloon ruptured producing a massive dissection of the LAD beginning immediately after the distal part of the undilatable lesion (Figure 1(c)). Rotawire was placed at the distal part of LAD. Rotational atherectomy was successfully performed with a 1.25 mm burr (Figure 1(d)), but the lesion was still undilatable with a 2 mm semicompliant balloon. Dilation was performed using 2.0 mm and 2.5 mm semicompliant balloons (Figure 1(e)) (Sprinter Legend, Medtronic) and the dissected and the previously undilated segment were stented. Three DES were placed in a row starting distally and moving proximally (Resolute Integrity, Medtronic) with a favorable angiographic result (Figure 1(f)).