Stent failure: OCT identification of false lumen wiring of distal stent edge dissection

Author(s): Ali Hillani, Jorge Chavarria, Gustavo Dutra, Matthew Sibbald

Background: Coronary artery dissection occurring during or at the end of the percutaneous intervention may lead to vessel closure and are significantly associated with increased short-term risk of major adverse cardiovascular events. Although the occurrence of final residual dissections has been reduced in the current era. The use of Optical Coherence Tomography (OCT) may show the exact position of the wire and helps prevent serious complications of stenting a long false lumen segment.

Case summary: A 52-year-old male patient presented for inferior ST Elevation Myocardial Infarction (STEMI) after one hour of oppressive chest pain. Coronary angiogram revealed, apart from a significant lesion at the ostium of the first Diagonal branch (Dg) which it was deferred for staged PCI, a 99% lesion of the Left Circumflex (LCX) that was immediately addressed by Primary Percutaneous Intervention (PPCI). One hour after PCI of Dg branch, he developed anterior STEMI and invasive angiogram showed patent stents in LCX and LAD into the Dg with a flush occlusion of the mid LAD just after the stent. The OCT identified the location of wire exiting into the false lumen, and the relative position of the true lumen opposite the carina, allowing redirection of the wire into the true lumen, which was confirmed in a subsequent OCT.

Conclusion: In our patient, balloon angioplasty of the mid LAD induced an iatrogenic edge dissection which caused subsequent artery occlusion either through spiral propagation or inadvertent false lumen wiring. OCT was instrumental in diagnosing these complications and correcting them.