Left internal mammary spasm mimicking graft dissection in the course of percutaneous coronary intervention of anastomotic in-stent restenosis

摘要

The percutaneous coronary intervention (PCI)of left internal mammary artery (LIMA) bypass toleft anterior descending artery (LAD) confers highrisk of intractable spasm and graft dissection. Thiscase presents a 67-year-old male, following coronary artery bypass grafting and PCI of LIMA-LADanastomosis with drug-eluting stent implantation7 months prior to index hospitalization, who currently presented with inferior wall ST-segmentelevation acute myocardial infarction. The coronaryangiography performed via right femoral approachshowed new significant 90% stenosis within thefirst diagonal branch and 99% in-stent restenosisin LIMA-LAD anastomosis (Fig. 1A). First, thelesion in LAD/diagonal branch was predilated witha 2.5 mm balloon and a 2.5 × 25 mm sirolimus--eluting stent was implanted. Second, an internalmammary artery guiding catheter was employedand the Whisper LS? guidewire was advancedacross the LIMA-LAD restenosis. The lesion wasinitially predilated with the 2.5 mm balloon anda 2.0 × 23 mm everolimus-eluting stent wasimplanted (Fig. 1B). Following stent deployment,a severe impairment of LIMA-LAD flow wasdocumented (Fig. 1C, Suppl. Movie 1), whichwas accompanied by aggravation of restrosternal chest pain and reduction of blood pressure(90/60 mmHg). Although LIMA dissection wassuspected, double intracoronary bolus of diluted0.1 mg nitroglycerine led to gradual restorationof Thrombolysis in Myocardial Infarction 3 bloodflow (Fig. 1D) and, paradoxically, improvement ofhemodynamic status (130/80 mmHg). The patientwas discharged home following an uneventfulfurther in-hospital stay. Iatrogenic periproceduralLIMA constriction should always be suspectedand vasodilative agents utilized in cases of impaired flow during LIMA PCI.