PMC4774942_01
A) LAO 30  view of normal RCA initial angiogram. B) Type F spiral dissection of RCA from ostium to crux with large false lumen opacification. C) With ongoing contrast injection, perforation of contrast back into true lumen of PL, PDA remains occluded. D) Wire placed through false lumen in mid-RCA into distal true lumen of PL. E) Two bare metal stents implanted in ostial to mid-RCA restoring TIMI 3 flow to PL. F) Pilot wire used to perforate back into PDA with ostial PDA hazy dissection. G) Small drug eluting stent implanted at ostium of PDA. H) Residual mid-distal PDA dissection.
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RCA was normal (Fig. 1A). Repeat angiography demonstrated a spiral dissection (type F) of the RCA from the ostium to the crux beyond which the vessel was occluded on first injection (Fig. 1B). In fact, the continued first injection spread the dissection (hydraulic) into the posterolateral (PL) branch with reentry of contrast perforating into the true lumen distally with branches of the PL visible (Fig. 1C). Immediately the RCA ostium was engaged at a slight distance from the ostium with a JR 4 guiding catheter and Pilot 50  wire (Abbott Vascular Inc.) was advanced into the distal PL (Fig. 1D). Both were post-dilated with a 3.75 mm non-compliant balloon at high pressures (18 atm) throughout (Fig. 1E). After repeated attempts, the Pilot-50 wire was able to perforate from this distal false lumen into the occluded PDA (Fig. 1F). There was obvious dissection seen at the ostium of the PDA with distal true lumen re-entry of the PDA with all branches and perforators visualized (Fig. 1F). To achieve as complete a revascularization as possible, it was decided to place a 2.25 x 12 mm drug eluting stent at the ostium of PDA with restoration of good flow into the distal PDA (Fig. 1G). There was a discrete residual dissection seen in the mid-PDA in the RAO (right anterior oblique) view likely demonstrating the point of reentry to true lumen of the PDA (Fig. 1H).
A) LAO 30  view RCA one year post stenting demonstrating initial true lumen stenting followed by occluded false lumen stents (arrows) and recanalized true lumen in a helical configuration. B) RAO 30  view of same RCA demonstrating side by side placement of recanalized true lumen and unopacified false lumen stents in a spiral fashion similar to the original planes of dissection.
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Angiography revealed that the proximal half of the ostial RCA stent was patent with mild restenosis at the ostium (Fig. 2A). This pattern continued into the previously placed mid-RCA stent which was also occluded, again with an adjacent lumen recanalized beside the occluded midbody stent (Fig. 2A and B). This true lumen recanalization appeared to form a helix around the occluded stents, likely representing the original course of the spiral dissection (Fig. 2A and B).
Reformatted images from an ECG-gated CT coronary angiogram. A) Transverse and (B) curved planar reformation of the mid-right coronary artery, and (C) transverse and (D) curved planar reformation of the distal right coronary artery and proximal posterior descending artery. These demonstrate unopacified stents (arrows) spiraling around the true lumen (*) of the right coronary artery and adjacent to the true lumen (*) of the proximal posterior descending artery. RA, right atrium; RV, right ventricle.
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Gated computed tomography (CT) coronary angiogram obtained prior to coronary artery bypass graft (CABG) revealed a patent proximal segment of stent (true lumen) with subsequent occlusion (non-opacified) of the remainder length of both stents (likely false lumen) with true lumen recanalization around the stents of reasonable caliber in spite of aggressive initial post dilation of the original stents which could have potentially caused the complete collapse of the true lumen (Fig. 3A-D). However, an adjacent slender lumen of contrast was visualized again likely indicating true lumen recanalization around the stent (Fig. 3C and D).