Where is the true lumen?

TLGeraud Souteyrand & Pascal Motreff
Cardiology Department, CHU Clermont-Ferrand

A 59 year-old man is admitted in our institution for a first STEMI

His medical history includes a previous ischemic stroke with residual hemiplegia, dyslipidemia and previous smoking.

The diagnosis is made by mobile care unit physicians at H4 . Initial EKG depict ST elevation in the anterior leads. The patient is referred to our cath lab for emergent coronary angiography

Coronary angiography is performed at H5, through right transradial approach. A 6 Fr EBU 3.5 guiding catheter is used.

Initial angiography shows an occluded proximal LAD with TIMI 0 flow

Figure 1

Ad hoc PCI is decided. Initial attempt to cross the lesion with BMW wire failed, leading to the use of stiffer wires.

Unfortunately, an iatrogenic dissection of left main and ostial is observed on control angiography.

Thus, a different strategy is decided: JL 3.5 guiding catheter and softer wire that is poked in the distal LAD with difficulty.

However, no flow is observed in the vessel after this approach 

As we wondered if the wire was correctly placed in the true lumen, and despite the lack of antegrade flow, we decide to go for OFDI analysis of the vessel

The analysis confirms that the wire was in correct position in distal LAD. Thus, proximal and mid-LAD PCI are subsequently performed with 3.5×18 mm and 3.0 x 18 mm EES.

However, no antegrade flow is observed following stents implantation

Figure 2

and a new OFDI run is decided.

It confirms that the wire is still in the true lumen and an additional PCI is decided in the distal part of the mid-LAD.

The final angio result is satisficing with TIMI 3 flow

Figure 3

Final OFDI run confirms the lack of any significant dissection

The clinical evolution was good with no residual chest pain, CPK peak=400 IU/ml and LVEF=55% at discharge.

Subsequent control is scheduled one month after the initial procedure.

Coronary angiography depicts excellent result

Figure 4

Figure 5

but OFDI

shows significant struts malappositions that are treated with non-compliant balloon post dilations.

In Summary:

  • Iatrogenic dissection during primary PCI procedure are unusual and are very challenging.
  • OFDI analysis is a valuable option to guide PCI in this situation