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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 14  |  Issue : 1  |  Page : 54-56

Accidental injury of the right coronary artery during angioplasty of the left coronary system


Department of Cardiology, R. G. Kar Medical College and Hospital, Kolkata, West Bengal, India

Date of Web Publication10-Mar-2017

Correspondence Address:
Biswajit Majumder
Department of Cardiology, R. G. Kar Medical College and Hospital, 1, Khudiram Bose Sarani, Kolkata - 700 004, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0189-7969.201911

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  Abstract 

Injury to coronary arteries can occur during diagnostic and therapeutic interventions. It is more common with angioplasty with certain guide catheters such as Amplatz catheter. The dissection is more common in ascending aorta with extension to the coronary arteries. We hereby report a case of right coronary artery (RCA) dissection without concurrent aortic dissection caused by injury with extra-backup left guide catheter during angioplasty of left anterior descending artery successfully managed by stenting of RCA from ostium with drug-eluting stent.

Keywords: Accidental injury, angioplasty, dissection, right coronary artery


How to cite this article:
Majumder B, Ghosh S, Sudeep K N, Chatterjee PK. Accidental injury of the right coronary artery during angioplasty of the left coronary system. Nig J Cardiol 2017;14:54-6

How to cite this URL:
Majumder B, Ghosh S, Sudeep K N, Chatterjee PK. Accidental injury of the right coronary artery during angioplasty of the left coronary system. Nig J Cardiol [serial online] 2017 [cited 2019 Dec 8];14:54-6. Available from: http://www.nigjcardiol.org/text.asp?2017/14/1/54/201911


  Introduction Top


Catheter-induced injury to coronary artery during diagnostic and therapeutic coronary interventions is not very uncommon. It is much more common during angioplasty by certain guide catheters such as Amplatz catheter than during diagnostic coronary angiography by diagnostic catheter.[1] Prompt recognition of this condition with timely intervention is required to avoid potentially catastrophic consequences. Here, we report a case of right coronary artery (RCA) dissection caused by injury with extra-backup left-guided catheter during angioplasty of the left anterior descending (LAD) artery by radial route. It was managed successfully by stenting of RCA from ostium with drug-eluting stent.


  Case Report Top


A 56-year-old female, nonhypertensive and nondiabetic, presented to cardiology department with a history of 3 hours severe retrosternal chest pain. Electrocardiography showed T-wave inversion from V1 to V6. Troponin T was positive. Echocardiography showed no regional wall motion abnormality and normal left ventricular systolic function. Clinical diagnosis of acute coronary syndrome was made. She was put on aspirin, clopidogrel, nitrate, beta blocker, statin, and injection heparin intravenously. With treatment, the patient became stable. Coronary angiography done through radial route showed a significant lesion in mid-LAD artery. Left circumflex artery was normal. RCA showed minor disease in proximal part. The patient was taken for percutaneous transluminal coronary angioplasty (PTCA) with stenting of LAD artery through radial route. Extra-backup 6-French guiding catheter was taken to engage the left main coronary artery (LMCA). There was some difficulty in engaging LMCA which required repeated manipulation. After engagement of LMCA, PTCA with stenting was done to LAD with drug-eluting stent [Figure 1]. During angioplasty of LAD, the patient began to experience severe pain in the chest and ST segment elevation in lead II, III, aVF, and hypotension with complete heart block. Immediately, temporary pacing was done, and the patient was put on inotropes. Check angiogram of RCA showed complete occlusion of RCA in proximal part by dissection flap without any dissection in aorta, probably caused by injury to RCA by extra-backup guide catheter during manipulation for engagement of LMCA. RCA lesion was crossed with floppy wire by some manipulation, and a 3.8 mm × 3.5 mm drug-eluting stent was implanted starting from RCA ostium [Figure 2]. Immediately after stenting of RCA, the patient became stable with disappearance of complete heart block, improvement of blood pressure, and reduction of chest pain and normalization of ST segment. Inotropes were tapered off and temporary pacemaker was removed and the patient was discharged in stable condition after 3 days. Aortic root angiogram did not reveal any aortic dissection. She is now doing well in 2-year follow-up.
Figure 1: Coronary angiography showing a significant disease in mid left anterior descending artery (a) treated with percutaneous transluminal coronary angioplasty and stenting to left anterior descending artery (b)

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Figure 2: Dissection flap in proximal right coronary artery noted with TIMI 0 flow distally (a and b) was wired successfully with floppy percutaneous transluminal coronary angioplasty wire (c) and treated with percutaneous transluminal coronary angioplasty and stenting with subsequent restoration of TIMI 3 flow to the right coronary artery (d)

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  Discussion Top


Injury to RCA by guide catheter during angioplasty of the left coronary system is rare. It is more common during angioplasty by radial route because guide catheter always has a tendency to go to the right coronary cusp and to cause injury to RCA.[2] Prompt recognition of the condition and quick stenting starting from ostium are required to avoid adverse outcome.

Though few cases have been reported compromising RCA ostium because of dissection flap from aorta caused by aortic dissection due to injury by guide catheter, especially by Amplatz catheter, direct injury of RCA by guide catheter without aortic dissection is extremely rare.[3],[4] Dissection of RCA may extend proximally into the aorta causing aortic dissection with its extension, immediate stenting of ostium of RCA is needed to limit its extension into aorta. In our case, during manipulation of extra-backup guide catheter, it has probably gone deep into the ostium of RCA which has some minor disease and caused the dissection. Guide catheter-induced injury to the coronary artery is not very uncommon. During guide catheter manipulation, injury can occur in RCA or in the left coronary system. Quick recognition of the condition is utmost importance to prevent any adverse outcome. In our case, ST segment elevation and hypotension and complete heart block gave the clue that some injury has occurred to RCA. During angioplasty if any hemodynamic and ST-T changes occur that cannot be explained by vascular compromise of the same territory, vascular compromise of other territory should be suspected.


  Conclusion Top


Though guide catheter-induced dissection of aorta with vascular compromise of RCA ostium has been reported in few cases during angioplasty, direct injury to RCA ostium causing dissection by guide catheter without aortic dissection during angioplasty of the left coronary system is extremely rare and probably not reported previously.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Boyle AJ, Chan M, Dib J, Resar J. Catheter-induced coronary artery dissection: Risk factors, prevention and management. J Invasive Cardiol 2006;18:500-3.  Back to cited text no. 1
    
2.
Dunning DW, Kahn JK, Hawkins ET, O'Neill WW. Iatrogenic coronary artery dissections extending into and involving the aortic root. Catheter Cardiovasc Interv 2000;51:387-93.  Back to cited text no. 2
    
3.
Wyss CA, Steffel J, Lüscher TF. Isolated acute iatrogenic aortic dissection during percutaneous coronary intervention without involvement of the coronary arteries. J Invasive Cardiol 2008;20:380-2.  Back to cited text no. 3
    
4.
Moles VP, Chappuis F, Simonet F, Urban P, De La Serna F, Pande AK, et al. Aortic dissection as complication of percutaneous transluminal coronary angioplasty. Cathet Cardiovasc Diagn 1992;26:8-11.  Back to cited text no. 4
    


    Figures

  [Figure 1], [Figure 2]



 

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