Accepted Manuscript

Optical Coherence Tomography-guided Bifurcation Stenting of a Coronary ArteryDissection

Nienke S. van Ditzhuijzen, Msc Jurgen Ligthart, Bsc Shengxian Tu, PhD Marc van derLinden, MD, PhD Evelyn Regar, MD, PhD

PII: S0828-282X(14)00239-6

DOI: 10.1016/j.cjca.2014.04.009

Reference: CJCA 1185

To appear in: Canadian Journal of Cardiology

Received Date: 6 February 2014

Revised Date: 1 April 2014

Accepted Date: 6 April 2014

Please cite this article as: van Ditzhuijzen NS, Ligthart J, Tu S, van der Linden M, Regar E, OpticalCoherence Tomography-guided Bifurcation Stenting of a Coronary Artery Dissection, Canadian Journalof Cardiology (2014), doi: 10.1016/j.cjca.2014.04.009.

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Optical Coherence Tomography-guided Bifurcation Stenting of a Coronary Artery

Dissection

Nienke S van Ditzhuijzen, Msc1,2, Jurgen Ligthart, Bsc1, Shengxian Tu, PhD3, Marc van der Linden, MD, PhD1,

Evelyn Regar, MD, PhD1

1Department of Cardiology, Thoraxcenter, 2COEUR Cardiovascular Research school, Erasmus University

Medical Center, Rotterdam, The Netherlands

3Division of Image Processing, Department of Radiology, Leiden University Medical Centre, Leiden,

Netherlands

Corresponding author

E. Regar

Department of Cardiology, Thoraxcenter, BA-585

Erasmus University Medical Center

‘s-Gravendijkwal 230, 3015 CE Rotterdam, The Netherlands

E-mail: e.regar@erasmsumc.nl

Keywords: Catheter-induced coronary artery dissection, optical coherence tomography, treatment

Word count: 1158; Figures: 2; Supplemental videos: 6

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Abstract

Periprocedural guide-wire induced coronary artery dissection is a rare but potentially serious complication of

PCI. Immediate stenting of the entry point is one of the therapeutic options but engaging the guide-wire in the

true lumen may be challenging. We report a case of a 55-year-old woman with a guide-wire induced coronary

dissection that occurred during treatment of a bifurcation lesion. Optical coherence tomography was instrumental

to distinguish true form false lumen and thereby guide correct positioning of the guide-wire to successfully treat

the lesion using a dedicated bifurcation stent.

Summary

Guide-wire induced coronary artery dissection is a rare but potentially serious complication of PCI. Engaging the

guide-wire in the true lumen may be challenging. We report a case where OCT was instrumental to distinguish

true from false lumen and thereby guide correct guide-wire positioning and reconstruct the true lumen.

Case report

A 55-year old female was referred for PCI with stable angina (CCS class III). Coronary angiography

demonstrated a stenosis at the bifurcation of the left anterior descending artery (LAD) with the second diagonal

branch (D2) (Figure 1A). After wiring the LAD and D2 (both Hi-torque pilot 50; Abbott Vascular), the

angiogram suggested a dissection at D2 (Figure 1B) and guide-wire positioning in the false lumen. Multiple

attempts to position the guide-wire in the true lumen were unsuccessful.

As an alternative to repeated angiograms using multiple projections, and to understand the spatial

relationship between the actual guide-wire position, the true lumen and the dissection flap, a single optical

coherence tomography (OCT; C7XR) of the D2 was performed (automated pullback 20mm/sec). OCT

confirmed the dissection – demonstrating that the entry point was situated very proximally to the side-branch

ostium – , the guide-wire position in the false lumen and clearly identified the true lumen (Figure 1C;

Supplemental video S1). 3D rendering helped to understand the spatial relationship between guide-wire position

and true and false lumen (Intage realia and QAngioOCT; Medis Specials) (Figures 1D+E and supplemental

video S2). Using a parallel guide-wire technique, one wire was left in the false and a second wire (Hi-torque

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BMW; Abbott Vascular, USA) was placed in the true lumen of the D2 (Figure 2A; Supplemental video S3).

OCT confirmed correct positioning of the second wire and clearly visualized the entry point of the dissection at

the side-branch ostium (Figure 2B+C; supplemental video S4). The entry point of the dissection was successfully

treated with a 3.0/2.5x18.0mm Nile Pax bifurcation stent (Minvasys). The final angiogram demonstrated good

clinical result with TIMI 3 flow (Figure 2D; Supplemental video S5). Six months after index procedure, routine

follow-up angiography demonstrated resolution of the coronary dissection with TIMI 3 flow (Supplemental

video S6).

Coronary dissections are rare but serious complications of the treatment of bifurcation lesions.1

Immediate stenting of the entry point is one of the therapeutic options but engaging the guide-wire in the true

lumen may be challenging since the relative low resolution of angiography only allows the reflection of luminal

dimensions. OCTprovides an unmatched high-resolution visualization of the coronary artery and could be

helpful in these complex situations.2 In our case, OCT demonstrated 1) guide-wire position in the false lumen

and allowed to correct the guide-wire position into the true lumen and 2) clearly demonstrated that the entry

point of the dissection was situated very proximally at the side-branch ostium, guiding stent selection. A

dedicated bifurcation stent was chosen that allowed full coverage of the entry point of the dissection at the carina

of the LAD and D2.

Alternatively, intravascular ultrasound (IVUS) could be used. IVUS employs a lower image resolution

than OCT (100µm vs. 10-15µm), but can image deeper into the tissue than OCT (penetration depth 4-10 mm vs.

1-2 mm), which could be helpful for the visualization of larger vessel dissections.3 Furthermore, IVUS can

image through blood, whereas OCT requires flushing during pullback acquisition that may increase

intracoronary pressure by approximately 10mmHg, possibly aggravating coronary dissections. 4 However, the

increased intracoronary pressure is well within a physiologic range and not considered a safety hazard. More

importantly, we did not see any signs of progression of the dissection in our patient.

In conclusion, in our case, the high resolution and sharp contrast of OCT offered advantages. The sharp

contrast between lumen and vessel wall proved to be crucial for clear visualization of the dissection membrane,

entry and exit point, true lumen, and false lumen. Furthermore, the fast image acquisition of OCT (automated

pullback 20 mm/sec versus 0.5-1.0mm/sec for IVUS), allowed for accurate three-dimensional reconstruction of

the complex anatomical situation that proved to be helpful for the operator to plan treatment strategy.

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Figure legends

Figure 1 Pre-intervention imaging

A) Coronary angiography demonstrates a stenosis at the bifurcation of the LAD with D2. B) After wiring, the

angiogram suggested a dissection at D2. C) OCT of the D2 confirmed the dissection at the bifurcation with the

LAD and demonstrated positioning of the guide-wire in the false lumen. The red circle in the l-mode indicates

the entry point of the dissection, the red arrow indicates the LAD. D+E) 3D reconstructions clearly visualize the

true and false lumen, with a side branch in the true lumen (arrow)

Figure 2 Post-intervention results

A) Coronary angiography demonstrates one guide-wire in the LAD and two guide-wires in the D2. B+C) OCT

including 3D reconstructions confirm correct positioning of the second wire. D) Final angiography demonstrates

successful implantation of the stents and TIMI 3 flow E) Cartoon of the bifurcation stent

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REFERENCES

1. Carrie D, Karouny E, Chouairi S, Puel J. "T"-shaped stent placement: A technique for the treatment of

dissected bifurcation lesions. Catheterization and cardiovascular diagnosis. 1996;37:311-313

2. Prati F, Regar E, Mintz GS, et al. Expert review document on methodology, terminology, and clinical

applications of optical coherence tomography: Physical principles, methodology of image acquisition,

and clinical application for assessment of coronary arteries and atherosclerosis. European heart journal.

2010;31:401-415

3. Mintz GS, Nissen SE, Anderson WD, et al. American college of cardiology clinical expert consensus

document on standards for acquisition, measurement and reporting of intravascular ultrasound studies

(ivus). A report of the american college of cardiology task force on clinical expert consensus

documents. Journal of the American College of Cardiology. 2001;37:1478-1492

4. Gonzalo N, Serruys PW, Garcia-Garcia HM, vet al. Quantitative ex vivo and in vivo comparison of

lumen dimensions measured by optical coherence tomography and intravascular ultrasound in human

coronary arteries. Revista espanola de cardiologia. 2009;62:615-624

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Supplemental video legends

Supplemental video S1

Fourier-domain optical coherence tomography (FD-OCT) of the second diagonal branch (D2) demonstrates that

the entry point of the dissection is situated very proximally to the side-branch ostium

Supplemental video S2

Three-dimensional reconstruction of the FD-OCT pullback of the D2 clearly demonstrates that the guide-wire is

positioned in the false lumen

Supplemental video S3

The coronary angiogram demonstrates one wire in the LAD and 2 wires in the D2

Supplemental video S4

FD-OCT pullback of the D2 confirms correct positioning of the second wire in the true lumen

Supplemental video S5

The final coronary angiogram demonstrates TIMI III flow

Supplemental video S6

Routine 6 month follow-up coronary angiography demonstrates resolution of the coronary artery dissection and

TIMI III flow