PMC6276441_01
(a) Long segment of moderate to severe stenosis in the LAD. Arrows indicate the target segments for deployment of the stents. (b) Intima flap, following lesion predilatation (arrows).
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The left coronary system revealed a patent LMS, a tubular moderate to severe stenosis extending from the proximal to the mid segment of the left anterior descending artery (LAD) (Figure 1(a)), and a minor nonobstructive atheroma in a nondominant left circumflex artery (LCx). Following predilatation, we could easily identify an intima flap within the stenotic lesion (Figure 1(b)).
(a) Significant luminal stenosis at the level of two small diagonal branches (arrows) after deployment of the stents and postdilatation of the overlapping segment with the 3.5 mm stent balloon at 16 atmospheres. Stenosis did not resolve after intracoronary administration of two consecutive 300 mcg bolus doses of nitrates. (b) Further overlapping stenting resulted in propagation of the haematoma and significant distal luminal stenosis after the level of the two small diagonal branches (arrows).
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The succeeding cine-acquisition demonstrated a significant luminal stenosis at the outflow of the distal stent (Figure 2(a)), associated with new dynamic anterior ST elevation on the ECG and chest discomfort of the patient. As the patient was clinically unstable and rapidly deteriorating, we initially opted not to perform further assessment with an intravascular ultrasound (IVUS) and quickly treat the haematoma with an additional stent implantation, but after deploying a 2.5 x 18 mm Orsiro (BIOTRONIK) DES, the subintimal haematoma was propagated more distally with further subtotal occlusion of the vessel (Figure 2(b)).
(a) Inflation of a 2.5 mm cutting balloon at nominal pressure at the transition of the stent struts to the adjacent unstented reference segment (arrows). (b) Restoration of normal TIMI 3 flow after inflation of cutting balloon at nominal pressure (arrows).
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Then, we inflated the balloon at nominal pressure, exactly at the transition point between the distal edge of the stent and the adjacent unstented vessel wall (Figure 3(a)). TIMI 3 flow (Figure 3(b)).