Angio Quiz
 

ANGIO QUIZ
Intra-arterial Hematoma after Percutaneous Coronary Intervention of
Shepard’s Crook Right Coronary Artery
Sundeep Mishra
Associate Professor of Cardiology, All India Institute of Medical Sciences, New Delhi.
A 42 year gentleman presented with class III angina. He was a smoker, hypertensive and had a dyslipidemic profile. Coronary angiogram revealed that left coronary system was normal but a “Shepard’s Crook” right coronary artery (RCA) had a tight stenosis in the mid one-third part (Figure 1). The RCA was hooked with 6F AL 1 guiding catheter, the lesion
 
Figure 1 Tight stenosis in mid Shepard’s Crook RCA
 
Figure 2 Cypher ™ stent deployed in mid RCA
  Figure 3 Angiogram suggestive of “Accordian
Effect” proximal to deployed stent
 
  Figure 4 Cine angiogram done after withdrawing
the distal tip of the wire revealed that it was a
peri-stent dissection and not a pseudo-lesion

 

Correspondence: Sundeep Mishra, Associate Professor of Cardiology, All India Institute of Medical Sciences, New Delhi.
Email: drsundeepmishra@hotmail.com
Indian Heart J. 2009; 61:209-210
 
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Sundeep Mishra
 
Figure 5 Overlapping Cypher ™ stent to cover
peri-stent dissection
 
Figure 6 Subsequent angiogram was suggestive
of either type III dissection or type I perforation
in the proximal RCA
 
Figure 7 IVUS revealed presence of intra-arterial
hematoma
  Figure 8 Intra-mural hematoma was sealed by
3×8 Cypher ™ sten
 
Figure 9 Good end result
 
 
crossed with BMW ™ guidewire and stented with 3×18
Cypher ™ stent (Figure 2). Post stent cine angiogram revealed a lesion just prior to stent (Figure 3). A possibility of vessel straightening (accordion effect) was considered. However, cine angiogram done after withdrawing guidewire (till floppy end of the wire reached the lesion) revealed that it was a peristent dissection and not a pseudo-lesion (Figure 4). As such an over-lapping 3×13 Cypher ™ stent was deployed to cover the dissection (Figure 5). Check angiogram done revealed a good result in mid RCA but a new lesion in proximal RCA (Figure 6). Angiographically, lesion appeared to be either a Type III dissection or Type I perforation. Intravascular ultrasound (IVUS) was done to understand the pathology of the lesion. IVUS revealed that it was an intra-arterial hematoma probably caused by guide catheter injury to RCA (Figure 7). A 3×8 Cypher ™ stent was used to seal the intra-mural hematoma (Figure 8). Final cine angiogram revealed an excellent result (Figure 9).
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Indian Heart J. 2009; 61:209 -210