case_images: PMC7354665_01
case_images: Coronary angiography and percutaneous coronary intervention. (a) Left coronary angiography (right anterior oblique caudal view) revealed a dissection at the proximal site of the LAD extending from the LMT, suggestive of type 1 spontaneous coronary artery dissection (red arrow). (b) Coronary blood flow of the LAD was impaired after coronary angiography. (c) The IVUS-guided rewiring technique was performed, and the third guide wire (purple arrow) was inserted from the true lumen of the LCX to the true lumen of the LAD by referring to the IVUS findings of the dissected segment. (d and e) A drug-eluting stent was deployed to cover the dissected segment. (f) Final coronary angiography revealed acceptable results. LMT: left main trunk; LAD: left anterior descending artery; LCX: left circumflex artery; IVUS: intravascular ultrasound.
case_images: CRIC2020-8890538.001.jpg
case_images: PMC7354665_01_CRIC2020-8890538.001.jpg
case_images: fig1
case_images: Coronary angiography showed no significant atherosclerotic stenosis in the right coronary artery and LCX, but a dissection was found from the midportion of the LMT to the proximal site of the LAD, suggestive of type 1 SCAD (Figure 1(a), Video1). Because the coronary blood flow of the LAD was impaired from thrombolysis in myocardial infarction (TIMI) flow grade III to I after contrast injection (Figure 1(b)) and the patient had chest pain with ST elevation, we decided to perform urgent PCI. We then pulled the wire back and controlled it toward the true lumen of the LAD, which was located under the first guide wire from the right anterior oblique and caudal view (Figures 1(c) and 2(d)). After the successful rewiring from the true lumen of the LMT to distal LAD, we removed the first wire (Figure 2(e)) and deployed a drug-eluting stent (Resolute Onyx, 3.5 x 30 mm; Medtronic plc, Fridley, MN, USA) from the LMT to LAD (Figures 1(d), 1(e), and 2(f)). Final coronary angiography showed acceptable results and TIMI grade III flow in both the LAD and LCX (Figure 1(f)).
case_images: The scheme of the percutaneous coronary intervention. (a) The first guide wire passed through the false lumen from the midportion of the LMT to the proximal site of the LAD. (b) The second guide wire was inserted into the true lumen of the LCX. (c) The third guide wire was initially introduced into the true lumen of the obtuse marginal branch using a double-lumen catheter that was placed in the true lumen of the LCX. (d) We pulled the third guide wire back and controlled it toward the true lumen of the LAD, which was located under the first guide wire from the right anterior oblique and caudal view. (e) After the successful rewiring, the first guide wire was removed. (f) A drug-eluting stent was deployed from the LMT to LAD. LMT: left main trunk; LAD: left anterior descending artery; LCX: left circumflex artery; OM: obtuse marginal branch.
case_images: CRIC2020-8890538.002.jpg
case_images: PMC7354665_01_CRIC2020-8890538.002.jpg
case_images: fig2
case_images: Intecc Co., Ltd., Nagoya, Japan) was initially introduced into the distal LAD, but IVUS imaging revealed that the guide wire had passed through the true lumen of the left coronary artery ostium, false lumen at the ostium of the LCX, and true lumen of the distal LAD (true-false-true) (Figure 2(a)). In addition, the true lumen of the proximal LAD was compressed by the false lumen (Figure 3(a)), and no significant atherosclerosis was observed within the vessel on IVUS. We then inserted the second guide wire (SION Blue; Asahi Intecc Co., Ltd.) into the LCX (Figure 2(b)), and IVUS imaging confirmed that it had been placed in the true lumen from the LMT to LCX (Figure 3(b)). We initially inserted the third guide wire into the true lumen of the obtuse marginal branch using a double-lumen catheter that was placed in the true lumen of the LCX (Figure 2(c)). After the successful rewiring from the true lumen of the LMT to distal LAD, we removed the first wire (Figure 2(e)) and deployed a drug-eluting stent (Resolute Onyx, 3.5 x 30 mm; Medtronic plc, Fridley, MN, USA) from the LMT to LAD (Figures 1(d), 1(e), and 2(f)).
case_images: IVUS findings during percutaneous coronary intervention. (a) The first guide wire passed through the false lumen from the midportion of the LMT to the proximal site of the LAD, and the true lumen of the LAD was compressed by the enlarged false lumen (orange arrow). (b) The second guide wire was inserted into the LCX, and IVUS imaging confirmed that it had been placed in the true lumen from the LMT to LCX (yellow arrow). (c) The third guide wire passed entirely through the true lumen from the LMT to LAD (green arrow). LMT: left main trunk; LAD: left anterior descending artery; LCX: left circumflex artery; IVUS: intravascular ultrasound.
case_images: CRIC2020-8890538.003.jpg
case_images: PMC7354665_01_CRIC2020-8890538.003.jpg
case_images: fig3
case_images: Intecc Co., Ltd., Nagoya, Japan) was initially introduced into the distal LAD, but IVUS imaging revealed that the guide wire had passed through the true lumen of the left coronary artery ostium, false lumen at the ostium of the LCX, and true lumen of the distal LAD (true-false-true) (Figure 2(a)). In addition, the true lumen of the proximal LAD was compressed by the false lumen (Figure 3(a)), and no significant atherosclerosis was observed within the vessel on IVUS. We then inserted the second guide wire (SION Blue; Asahi Intecc Co., Ltd.) into the LCX (Figure 2(b)), and IVUS imaging confirmed that it had been placed in the true lumen from the LMT to LCX (Figure 3(b)). The IVUS-guided rewiring technique was successful, and the subsequent IVUS imaging confirmed that the third guide wire had passed entirely through the true lumen from the LMT to LAD (Figure 3(c), Video3).
case_images: Coronary CT angiography performed 12 months after percutaneous coronary intervention. (a) Follow-up coronary CT angiography revealed no atherosclerotic stenosis in both the right and left coronary arteries. (b) There were no clear findings of in-stent restenosis or incomplete stent apposition. CT: computed tomography.
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case_images: PMC7354665_01_CRIC2020-8890538.004.jpg
case_images: fig4
case_images: Follow-up coronary computed tomography (CT) angiography was performed 12 months after the procedure and showed acceptable results with no clear findings of in-stent restenosis or incomplete stent apposition (Figures 4(a) and 4(b)).