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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 14  |  Issue : 1  |  Page : 35-37

Paying for inadequate predilatation during angioplasty


Department of Cardiology, AIIMS, Bhubaneswar, Odisha, India

Date of Web Publication10-Mar-2017

Correspondence Address:
Ramachandra Barik
Department of Cardiology, AIIMS, Sijua, Patrapada, Bhubaneswar - 751 019, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0189-7969.201908

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  Abstract 

Adequate predilatation and balloon sizing of the lesion are must during coronary angioplasty. A well-prepared lesion not only responds well to stent expansion but also helps visualization of the lesion during stent implantation because of good antegrade flow despite the stent across the lesion. In this illustration, we just missed the distal part of lesion during angioplasty of critical stenotic lesion in the left anterior descending artery in a 54-year-old woman with crescendo angina despite predilatation. Because of inadequate predilatation, residual significance stenosis limited the forward flow of contrast when the stent was across the lesion for positioning before expansion. The narrow error in the judgment costed an additional stent to complete the procedure.

Keywords: Additional stenting, chronic total occlusion, coronary angioplasty, predilatation


How to cite this article:
Damera SR, Barik R. Paying for inadequate predilatation during angioplasty. Nig J Cardiol 2017;14:35-7

How to cite this URL:
Damera SR, Barik R. Paying for inadequate predilatation during angioplasty. Nig J Cardiol [serial online] 2017 [cited 2019 Dec 10];14:35-7. Available from: http://www.nigjcardiol.org/text.asp?2017/14/1/35/201908


  Introduction Top


Adequate preparation of lesions before stenting in selected cases of chronic stable angina is essential to avoid or reduce unnecessary complications. In this illustration, we share an experience in which our chosen stent length just fell short of the length of lesion. It costed an additional stent to complete the procedure.


  Case Report Top


A 54-year-old woman presented with recent onset of hypertension and exertional bilateral jaw pain for last 2 months. She was nondiabetic and euthyroid. Ultrasound of the abdomen was normal. The levels of blood urea and serum creatinine were in the normal limits. Coronary angiogram was through right radial access showed total occlusion of mid part of left anterior descending (LAD) coronary artery of length: 14 mm, diameter: 2.75 mm, J-CTO score: 1,[1] and Rentrop's Grade III ipsilateral and contralateral collaterals just opposite to the medium size second diagonal branch [Figure 1]a,[Figure 1]b,[Figure 1]c. Right coronary and left circumflex artery were normal. The lesion was assessed by quantitative angiogram. Renal artery angiogram was normal. Ad hoc angioplasty was planned with ticagrelor loading dose and proper anticoagulation. The lesion was crossed with ChoICE™ PT Extra Support Wire (Boston Scientific) after hooking left main coronary artery with 5Fr left extra backup guide (Medtronic Vascular) in the first attempt with support of small balloon. The lesion was predilated with 1.25 mm × 10 mm semi-compliant coronary balloon (Sprinter, Medtronic Vascular) with fair antegrade flow. The length of lesion was 15 mm after balloon dilatation measured by the balloon used for predilatation [Figure 1]d. A drug eluting stent of size 18 mm × 2.75 mm (XIENCE Prime Everolimus Eluting Coronary Stent System, Abbott Vascular) was tried to be implanted. However, neither the lesion segment nor the distal vessel was seen with stent across the lesion because of poor antegrade flow through the lesion [Figure 2]a. Then, the stent was pulled to guide catheter to reassess the lesion. Coronary artery spasm was ruled by intracoronary nitroglycerine (50 µg, 2 doses) and one dose of intracoronary verapamil [Figure 2]b.[2] The stent was implanted in the anterior cranial view (anterior-posterior [AP]) with ensuring exact covering of proximal end. The postdeployment angiogram showed, the distal end of stent is in the lesion [Figure 2]c. A bailout or an additional stent of size 12 mm × 2.5 (above category) was implanted with nominal pressure, i.e., 8–9 atmospheric pressure [Figure 2]d. The final angiographic flow was TIMI III [Figure 2]d.
Figure 1: (a) Total occlusion of left anterior descending coronary artery exactly after first diagonal (D1) opposite to the second diagonal branch (D2). (b) The proximal stump of left anterior descending is conical and well defined; however, distal left anterior descending is not seen. (c) Doubtful filling left anterior descending by bridging collaterals. (d) TIMI III flow in left anterior descending after predilatation

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Figure 2: (a) Complete cessation of antegrade flow in the left anterior descending after positioning the stent in the lesion (the stent was almost wedging the proximal conical end) because of inadequate space for contrast to flow between the stent and intima. (b) The stent was pulled out into the guide catheter, and a shot was taken after intracoronary nitroglycerine and verapamil. (c) Stent was deployed anterior-posterior cranial projection ensuring proximal end is in healthy segment and followed up angiogram showed distal part of lesion was missed. (d) An additional stent was deployed to achieve the final TIMI III flow as a compensation for the erroneous judgment

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  Discussion Top


In selected patients, direct stenting is feasible, safe and also reduces procedural time in both acute coronary syndrome (ACS) and chronic stable angina.[3],[4] However, an adequate lesion preparation, proper balloon sizing with respect to the length, and diameter of lesion are must in selected cases such as chronic critical stenosis, chronic total occlusion, and calcified lesions [4],[5],[6],[7],[8] which reduce procedural time, contrast volume, and increases lesion compliance. Adequate predilatation also avoids the need of additional stent by improving the perception of lesion during adjustment for correct position because of adequate forward flow. We feel our mistake in this index case could have been avoided by further dilating the lesion with a 2–2.25 mm semi-compliant or noncompliant balloon for better antegrade flow before implanting stent, i.e. proper lesion preparation.[9] The position of proximal end of stent could have been well delineated in crab view and anterior caudal (AP) projection because there significant overlapping of the first diagonal and LAD in anterior cranial (AP) and right anterior oblique cranial projection [Figure 2]. Direct stenting is quite useful in ACS and some selected cases of chronic stable angina. However, lesion preparation is almost unavoidable in some cases of chronic stable angina such as critical stenosis, total occlusion, and calcific lesion. An adequate predilatation in these situations improves lesion compliancy and visibility, saves time, contrast volume, and necessity of an additional stent.

Acknowledgments

I am extremely thankful to the local English editor, Miss Mimansa Barik for her kind help in editing the manuscript.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Morino Y, Abe M, Morimoto T, Kimura T, Hayashi Y, Muramatsu T, et al. Predicting successful guidewire crossing through chronic total occlusion of native coronary lesions within 30 minutes: The J-CTO (Multicenter CTO Registry in Japan) score as a difficulty grading and time assessment tool. JACC Cardiovasc Interv 2011;4:213-21.  Back to cited text no. 1
    
2.
Babbitt DG, Perry JM, Forman MB. Intracoronary verapamil for reversal of refractory coronary vasospasm during percutaneous transluminal coronary angioplasty. J Am Coll Cardiol 1988;12:1377-81.  Back to cited text no. 2
    
3.
Li C, Zhang B, Li M, Liu J, Wang L, Liu Y, et al. Comparing direct stenting with conventional stenting in patients with acute coronary syndromes: A meta-analysis of 12 clinical trials. Angiology 2016;67:317-25.  Back to cited text no. 3
    
4.
Baim DS, Flatley M, Caputo R, O'Shaughnessy C, Low R, Fanelli C, et al. Comparison of PRE-dilatation vs direct stenting in coronary treatment using the Medtronic AVE S670 coronary stent system (the PREDICT trial). Am J Cardiol 2001;88:1364-9.  Back to cited text no. 4
    
5.
Kandzari DE, Zankar AA, Teirstein PS, Brilakis ES, Banerjee S, Price MJ, et al. Clinical outcomes following predilation with a novel 1.25-mm diameter angioplasty catheter. Catheter Cardiovasc Interv 2011;77:510-4.  Back to cited text no. 5
    
6.
Chang SH, Chen CC, Hsieh MJ, Wang CY, Lee CH, Hsieh IC. Lesion length impacts long term outcomes of drug-eluting stents and bare metal stents differently. PLoS One 2013;8:e53207.  Back to cited text no. 6
    
7.
Nichols AB, Smith R, Berke AD, Shlofmitz RA, Powers ER. Importance of balloon size in coronary angioplasty. J Am Coll Cardiol 1989;13:1094-100.  Back to cited text no. 7
    
8.
Colombo A, Panoulas VF. After 3 decades, at long last, a new device to deal with calcific lesions. JACC Cardiovasc Interv 2014;7:519-20.  Back to cited text no. 8
    
9.
Farag M, Costopoulos C, Gorog DA, Prasad A, Srinivasan M. Treatment of calcified coronary artery lesions. Expert Rev Cardiovasc Ther 2016;14:683-90.  Back to cited text no. 9
    


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