Clinical Images

The “Zipper” Lesion: A Rare but Serious Guiding Catheter-Induced Complication of a PCI Procedure

Stéphane Cook, MD and David Tueller, MD
Stéphane Cook, MD and David Tueller, MD
A 42-year-old man presented with heavy chest pain of four hours’ duration. Physical examination was unremarkable. The ECG showed an acute septoapical infarction. Nitroglycerin, aspirin, clopidogrel and heparin were administered, and an emergency coronary angiography was performed from the right femoral artery (Figures 1 A and B). The left anterior descending artery was occluded distally. The left main trunk ostium was deeply intubated by a slightly too large Q4 6 French intervention catheter. There was, however, no damping or ventriculization of pressure. The occlusion was crossed with a guidewire, which restored normal blood flow in the vessel. During the lesion balloon dilatation, a large dissection-like intraluminal filling defect from the left ostium appeared and propagated rapidly in both major branches (Figures 2 A and B – arrowheads). The patient continued to experience intermittent chest discomfort because of intermittent occlusion of the proximal part of the OM1 branch of the circumflex artery and required urgent coronary artery surgery (left internal mammary artery graft to the proximal left anterior descending and vein grafts to the diagonal, the distal left anterior descending and circumflex arteries). The postoperative course was complicated by pericardial tamponade requiring operative revision, and non ST-elevation myocardial infarction due to sudden occlusion of the vein graft to the diagonal artery. The subsequent recovery was uneventful and the patient was discharged in good condition on the eleventh postoperative day. Angiography performed four months after the coronary artery bypass grafting confirmed a good surgical result (Figure 3). Catheter-induced coronary dissection is rare but carries a significant risk of mortality and morbidity. It occurs following a trauma caused either by the tip of the guiding catheter (unintended deep intubation) or after balloon dilation. Despite the lack of guidelines for the optimal treatment of extended left main coronary artery dissection during a PCI procedure, the usual management has been bailout aortocoronary bypass surgery,1 but some cases of successful intracoronary stenting have also been reported.2,3
References
1. Capdeville M, Lee JH. Emergency off-pump coronary artery bypass grafting for acute left main coronary artery dissection. Tex Heart Inst J 2001;28:208–211. 2. Mulvihill NT, Boccalatte M, Fajadet J, Marco J. Catheter-induced left main dissection: A treatment dilemma. Catheter Cardiovasc Interv 2003;59:214–216. 3. Hennessy TG, McCann HA, Sugrue DD. Bailout Palmaz-Schatz stenting for iatrogenic dissection of the left main coronary artery. J Invasive Cardiol 1996;8:450–452.