Catheterization and Cardiovascular Diagnosis 26:136-139 (1992)
Mechanical Right Coronary Artery Shortening and Vessel Wall Invagination: A Fourth Cause of Iatrogenic Coronary Obstruction During Coronary Angioplasty. A Case Report and Review of the Literature Patrick J. Shea, MD Coronary spasm, dissection, and localized thrombosis are recognized sources of iatrogenic obstruction during coronary angiopiasty. A fourth important cause is reported, namely, guidewireinduced mechanical straightening and shortening of tortuous right coronary artery resulting in the invagination of redundant vascular tissue. Reversal is achieved with guidewire retraction. Recognition of this entity is crucial to avoid unnecessary and potentially harmful intervention. 0 ISM wiiey-uu, IN. Key words: angioplasty complication, dissection, mechanical stenosis, pseudostenosis
INTRODUCTION The unexpected appearance of a flow-limiting extralesional coronary obstruction during percutaneous transluminal coronary angioplasty (FTCA) requires rapid recognition and diagnosis followed by appropriate intervention. Recognized mechanisms of occlusion include coronary artery spasm, subintimal dissection, and localized coronary thrombosis [ 11. Recently, reversible obstruction in an internal mammary artery graft [2] and in several native right coronary arteries associated with guidewire placement have been In each case the lesion was unresponsive described [3,4]. to intracoronary nitroglycerin administration. We report an additional case of a patient who developed a unique appearing focal rectilinear coronary obstruction, partially responsive to intracoronary nitroglycerin associated with guidewire placement and vessel shortening during PTCA. CASE REPORT A 69-yr-old white male presented with 90 min of ischemic-type chest discomfort after mowing the lawn. An ECG demonstrated an acute inferior wall myocardial infarction pattern. He received 1.5 million U of intravenous streptokinase (SK) over 1 h and experienced prompt improvement in chest discomfort at approximately 40 min into the infusion. He received intravenous heparin after SK infusion was complete. His activated partial thromboplastin time was maintained between 50 and 90 s. He had a brief episode of postinfarction angina that responded to intravenous nitroglycerin. 0 1992 Wiiey-Liss, Inc.
Cardiac Catheterization Coronary angiography 24 h later revealed a dominant right coronary artery with a superior takeoff and mild tortuosity of the middle segment. There was a 90% very discrete “web-like” lesion after the origin of the acute marginal branch (Fig. 1). The right anterior oblique ventriculogram demonstrated moderate to severe hypokinesis of the inferobasal segment with some normalization following a premature ventricular contraction. The left ventricular ejection fraction was 66%. Coronary Angioplasty Angioplasty of the right coronary artery was performed via the right femoral artery. Heparin, 10,OOO U, was administered intravenously and activated clotting times were maintained greater than 300 s. A 0.014HiTorque Floppy (ACS, Inc.) guidewire was advanced into the distal right coronary artery without difficulty via an 8 French JR4, 0.079-in. internal diameter (Schneider, Inc.) guiding catheter. An appropriately sized 3.0 cm ACX I1 (ACS, Inc.) dilating catheter was advanced across the lesion and inflated for a maximum of 5 atmospheres of pressure for a
From the Division of Cardiology,Departmentof Medicine, The Christ Hospital, Cincinnati, Ohio. Received October 21, 1991; revision accepted December 6, 1991. Address reprint requests to Dr. Patrick J . Shea. Cardiovascular Specialists, Inc., 10506 Montgomery Rd., Suite 504, Cincinnati, OH
45242.
Mechanical Coronary Artery lnvagination
Fig. 1. Angiogram prior to angioplasty. Arrow denotes the target lesion.
total of 3 min. The dilating catheter was withdrawn over the guidewire. Repeat coronary angiography demonstrated a very eccentric 70-8096 focal stenosis with rectilineal borders at the site of the first major bend in the proximal vessel measuring approximately 2 . 3 mm in length (Fig. 2). No staining or extravasation of dye was noted. There were no persistent linear radiolucencies. Intracoronary nigroglycerin (300 pg) was administered. Repeat angiography demonstrated a persistent stenosis of approximately 70-80% but now measuring approximately 1.0 mm in length. The angiographic appearance suggested an invaginated fold of vascular tissue. Loss of the upward takeoff in the proximal segment and of the tortuosity in the middle segment was noted at that point (Fig. 3). The guidewire was withdrawn into the guiding catheter and repeat angiography was performed immediately. The preangioplasty tortuosity was restored, and the proximal right coronary artery lesion had resolved completely (Fig. 4).The target lesion demonstrated less than 20% residual stenosis. Repeat angiography was performed 20 min following the withdrawal of the guidewire and the vessel remained unchanged. The patient was maintained on heparin overnight. He was discharged home the following morning. The subsequent treadmill stress test was within normal limits.
DISCUSSION Mechanically induced coronary spasm has been well known since the early years of angiography. During PTCA it is typically precipitated by irritation from the tip of the guidewire, dilating catheter, or guide catheter. It is diagnosed by the sequential presence of patency,
137
Fig. 2. Immediately following angioplasty with guidewire positioned in the distal right coronary artery and dilating catheter wlthdrawn. Arrow indicates a new 7040% stenosis proximal to the target lesion. Note the straightening and shortening of the proximal and middle segments.
Fig. 3. After 300 pg intracoronary nitroglycerin the new stenosis has decreased in length.
smoothly tapered obstruction, and finally, return to the original anatomy [I]. Supporting evidence includes manipulation in the area of suspected spasm, and the response to intracoronary vasodilators and removal of the irritant stimulus. The patient reported here demonstrated a highly eccentric lesion. It responded partially to intracoronary nitroglycerin with reduction in the lesion length, but severe eccentric “fold-like’’ stenosis remained. Occlusions proximal to the dilated segment suggest the presence of subintimal passage of the guidewire or catheter resulting in dissection. Dissection is recognized angiographically by the presence of an intimal tear re-
138
Shea
Fig. 4. Final angiogram after the guidewire was wlthdrawn, demonstrating successful dilatation of the target lesion and resolution of both the normal vessel tortuoslty and the extralesional stenosis.
sulting in the longitudinal extravasation of dye, “haziness,” and/or cross hatching areas of linear radiolucencies [ 5 ] . Appropriate treatment includes immediate redilatation. In resistant lesions, prolonged balloon inflation utilizing a perfusion catheter, coronary artery bypass graft surgery, coronary stents, rescue directional atherectomy and laser or thermal balloon angioplasty have been utilized [5-81. The typical angiographic findings of dissection were not observed in the case reported here. The presence of localized coronary thrombus is suggested angiographically by the presence of contrast media surrounding an intraluminal filling defect that is often pedunculated in contour. This is frequently accompanied by dye staining. Distal embolization supports this diagnosis. Appropriate treatment would include repeat dilatation, intracoronary thrombolytic therapy, and possibly laser or thermal balloon angioplasty or extraction atherectomy. In contrast, our patient demonstrated a rectilinear filling defect without dye staining or embolization. Grewe [2] recently reported torsion of a redundant internal mammary artery graft during PTCA of the left anterior descending artery resulting in a rectilinear “stair step” deformity and straightening of the vessel that resolved with guidewire removal. Tengalis et al. [3] reported one case and Rauh et al. [4]reported two cases with right coronary artery straightening followed by focal proximal arterial narrowing. The lesions were unresponsive to intracoronary nitroglycerin and resolved when the guidewire and dilating catheters were withdrawn. These cases suggest a mechanical deformation of the redundant arterial segments. The right coronary ar-
tery is fixed at the ostium and at the right atrio-ventricular sulcus. However, the proximal and mid-right coronary artery is relatively untethered to the epicardium. Consequently, like the internal mammary artery graft, a tortuous right coronary artery may be subject to straightening and shortening due to the presence of an intracoronary guidewire. It is postulated that this shortening caused segmental invagination of the outer vessel wall along the curvature producing this atypical-appearing eccentric rectilinear obstruction. It is felt that the intracoronary nitroglycerin resulted in vascular smooth muscle relaxation and the angiographic appearance of “unfolding” of the invaginated segment. Retraction of the guidewire allowed the vessel to assume its normal tortuosity and restored normal patency. The incidence of mechanical obstruction of the right coronary artery remains uncertain. Teneglis [3] estimates from the Duke experience that it occurs as frequently as 1 in 250 PTCAs involving the right coronary artery. Clinical Implications
Mechanical right coronary artery shortening and vessel wall invagination represent a fourth important cause of iatrogenic coronary obstruction during PTCA. This entity must be suspected in the presence of significant guidewire-induced straightening of a tortuous vessel and the atpical morphologic features described above. Incorrect diagnosis of this apprently benign complication of PTCA could result in inappropriate therapy, additional vascular trauma, and potentially life-threatening consequences. ACKNOWLEDGMENTS
The author wishes to thank Drs. Charles Abottsmith and Richard Henthorn for their review of the manuscript and Beverly Lohr for her secretarial assistance. REFERENCES 1 . Cowley MJ, Doms G , Kelsey SF, VanRaden M, Detre K: Acute coronary events associated with percutaneous transluminal coronary angioplasty. Am J Cardiol 53:12C-I6C,1984. 2. Grewe K, Presti C, Perez JA: Torsion of the internal mammary graft during PTCA: A case report. Cathet Cardiovasc Diagn 19: 195-197, 1990. 3. Tenaglia AN, Tcheng JE, Phillip HR, Stack R: Creation of pseudonarrowing during coronary angioplasty. Am J Cardiol 67:658-
659, 1991. 4. Rauh RA, Ninneman RW, Joseph D, Gupta VK, Senin DG,Miller W: Accordion effect in tortuous right coronary arteries during percutaneous transluminal coronary angioplasty. Cathet Cardiovasc Diagn 23:107-110,1991. 5. Angelini P: “Balloon Catheter Coronary Anpioplasty.” New Yoik: Future Publishing Co., 1987, pp 135-142: ~
Mechanical Coronary Artery lnvagination 6. Waller B F 'Crackers, breakers, stretches, drillers, scrapers, shav-
ers, burners, welders and melters.' The future treatment of atherosclerotic coronary artery disease? A clinical morphologic assessment. J Am Coll Cardiol 13:969-987, 1984. 7. Spears JR, Reyes VP,Wynne J, et al.: Percutaneous coronary laser
139
balloon angioplasty: Initial results of a multicenter experience. J Am Coll Cardiol 16:293-303, 1990. 8. Shatz RA: A view of vascular stents. Circulation 79:445-457, 1989.
Mechanical Right Coronary Artery Shortening and Vessel Wall Invagination: A Fourth Cause of Iatrogenic Coronary Obstruction During Coronary Angioplasty. A Case Report and Review of the Literature Patrick J. Shea, MD Coronary spasm, dissection, and localized thrombosis are recognized sources of iatrogenic obstruction during coronary angiopiasty. A fourth important cause is reported, namely, guidewireinduced mechanical straightening and shortening of tortuous right coronary artery resulting in the invagination of redundant vascular tissue. Reversal is achieved with guidewire retraction. Recognition of this entity is crucial to avoid unnecessary and potentially harmful intervention. 0 ISM wiiey-uu, IN. Key words: angioplasty complication, dissection, mechanical stenosis, pseudostenosis
INTRODUCTION The unexpected appearance of a flow-limiting extralesional coronary obstruction during percutaneous transluminal coronary angioplasty (FTCA) requires rapid recognition and diagnosis followed by appropriate intervention. Recognized mechanisms of occlusion include coronary artery spasm, subintimal dissection, and localized coronary thrombosis [ 11. Recently, reversible obstruction in an internal mammary artery graft [2] and in several native right coronary arteries associated with guidewire placement have been In each case the lesion was unresponsive described [3,4]. to intracoronary nitroglycerin administration. We report an additional case of a patient who developed a unique appearing focal rectilinear coronary obstruction, partially responsive to intracoronary nitroglycerin associated with guidewire placement and vessel shortening during PTCA. CASE REPORT A 69-yr-old white male presented with 90 min of ischemic-type chest discomfort after mowing the lawn. An ECG demonstrated an acute inferior wall myocardial infarction pattern. He received 1.5 million U of intravenous streptokinase (SK) over 1 h and experienced prompt improvement in chest discomfort at approximately 40 min into the infusion. He received intravenous heparin after SK infusion was complete. His activated partial thromboplastin time was maintained between 50 and 90 s. He had a brief episode of postinfarction angina that responded to intravenous nitroglycerin. 0 1992 Wiiey-Liss, Inc.
Cardiac Catheterization Coronary angiography 24 h later revealed a dominant right coronary artery with a superior takeoff and mild tortuosity of the middle segment. There was a 90% very discrete “web-like” lesion after the origin of the acute marginal branch (Fig. 1). The right anterior oblique ventriculogram demonstrated moderate to severe hypokinesis of the inferobasal segment with some normalization following a premature ventricular contraction. The left ventricular ejection fraction was 66%. Coronary Angioplasty Angioplasty of the right coronary artery was performed via the right femoral artery. Heparin, 10,OOO U, was administered intravenously and activated clotting times were maintained greater than 300 s. A 0.014HiTorque Floppy (ACS, Inc.) guidewire was advanced into the distal right coronary artery without difficulty via an 8 French JR4, 0.079-in. internal diameter (Schneider, Inc.) guiding catheter. An appropriately sized 3.0 cm ACX I1 (ACS, Inc.) dilating catheter was advanced across the lesion and inflated for a maximum of 5 atmospheres of pressure for a
From the Division of Cardiology,Departmentof Medicine, The Christ Hospital, Cincinnati, Ohio. Received October 21, 1991; revision accepted December 6, 1991. Address reprint requests to Dr. Patrick J . Shea. Cardiovascular Specialists, Inc., 10506 Montgomery Rd., Suite 504, Cincinnati, OH
45242.
Mechanical Coronary Artery lnvagination
Fig. 1. Angiogram prior to angioplasty. Arrow denotes the target lesion.
total of 3 min. The dilating catheter was withdrawn over the guidewire. Repeat coronary angiography demonstrated a very eccentric 70-8096 focal stenosis with rectilineal borders at the site of the first major bend in the proximal vessel measuring approximately 2 . 3 mm in length (Fig. 2). No staining or extravasation of dye was noted. There were no persistent linear radiolucencies. Intracoronary nigroglycerin (300 pg) was administered. Repeat angiography demonstrated a persistent stenosis of approximately 70-80% but now measuring approximately 1.0 mm in length. The angiographic appearance suggested an invaginated fold of vascular tissue. Loss of the upward takeoff in the proximal segment and of the tortuosity in the middle segment was noted at that point (Fig. 3). The guidewire was withdrawn into the guiding catheter and repeat angiography was performed immediately. The preangioplasty tortuosity was restored, and the proximal right coronary artery lesion had resolved completely (Fig. 4).The target lesion demonstrated less than 20% residual stenosis. Repeat angiography was performed 20 min following the withdrawal of the guidewire and the vessel remained unchanged. The patient was maintained on heparin overnight. He was discharged home the following morning. The subsequent treadmill stress test was within normal limits.
DISCUSSION Mechanically induced coronary spasm has been well known since the early years of angiography. During PTCA it is typically precipitated by irritation from the tip of the guidewire, dilating catheter, or guide catheter. It is diagnosed by the sequential presence of patency,
137
Fig. 2. Immediately following angioplasty with guidewire positioned in the distal right coronary artery and dilating catheter wlthdrawn. Arrow indicates a new 7040% stenosis proximal to the target lesion. Note the straightening and shortening of the proximal and middle segments.
Fig. 3. After 300 pg intracoronary nitroglycerin the new stenosis has decreased in length.
smoothly tapered obstruction, and finally, return to the original anatomy [I]. Supporting evidence includes manipulation in the area of suspected spasm, and the response to intracoronary vasodilators and removal of the irritant stimulus. The patient reported here demonstrated a highly eccentric lesion. It responded partially to intracoronary nitroglycerin with reduction in the lesion length, but severe eccentric “fold-like’’ stenosis remained. Occlusions proximal to the dilated segment suggest the presence of subintimal passage of the guidewire or catheter resulting in dissection. Dissection is recognized angiographically by the presence of an intimal tear re-
138
Shea
Fig. 4. Final angiogram after the guidewire was wlthdrawn, demonstrating successful dilatation of the target lesion and resolution of both the normal vessel tortuoslty and the extralesional stenosis.
sulting in the longitudinal extravasation of dye, “haziness,” and/or cross hatching areas of linear radiolucencies [ 5 ] . Appropriate treatment includes immediate redilatation. In resistant lesions, prolonged balloon inflation utilizing a perfusion catheter, coronary artery bypass graft surgery, coronary stents, rescue directional atherectomy and laser or thermal balloon angioplasty have been utilized [5-81. The typical angiographic findings of dissection were not observed in the case reported here. The presence of localized coronary thrombus is suggested angiographically by the presence of contrast media surrounding an intraluminal filling defect that is often pedunculated in contour. This is frequently accompanied by dye staining. Distal embolization supports this diagnosis. Appropriate treatment would include repeat dilatation, intracoronary thrombolytic therapy, and possibly laser or thermal balloon angioplasty or extraction atherectomy. In contrast, our patient demonstrated a rectilinear filling defect without dye staining or embolization. Grewe [2] recently reported torsion of a redundant internal mammary artery graft during PTCA of the left anterior descending artery resulting in a rectilinear “stair step” deformity and straightening of the vessel that resolved with guidewire removal. Tengalis et al. [3] reported one case and Rauh et al. [4]reported two cases with right coronary artery straightening followed by focal proximal arterial narrowing. The lesions were unresponsive to intracoronary nitroglycerin and resolved when the guidewire and dilating catheters were withdrawn. These cases suggest a mechanical deformation of the redundant arterial segments. The right coronary ar-
tery is fixed at the ostium and at the right atrio-ventricular sulcus. However, the proximal and mid-right coronary artery is relatively untethered to the epicardium. Consequently, like the internal mammary artery graft, a tortuous right coronary artery may be subject to straightening and shortening due to the presence of an intracoronary guidewire. It is postulated that this shortening caused segmental invagination of the outer vessel wall along the curvature producing this atypical-appearing eccentric rectilinear obstruction. It is felt that the intracoronary nitroglycerin resulted in vascular smooth muscle relaxation and the angiographic appearance of “unfolding” of the invaginated segment. Retraction of the guidewire allowed the vessel to assume its normal tortuosity and restored normal patency. The incidence of mechanical obstruction of the right coronary artery remains uncertain. Teneglis [3] estimates from the Duke experience that it occurs as frequently as 1 in 250 PTCAs involving the right coronary artery. Clinical Implications
Mechanical right coronary artery shortening and vessel wall invagination represent a fourth important cause of iatrogenic coronary obstruction during PTCA. This entity must be suspected in the presence of significant guidewire-induced straightening of a tortuous vessel and the atpical morphologic features described above. Incorrect diagnosis of this apprently benign complication of PTCA could result in inappropriate therapy, additional vascular trauma, and potentially life-threatening consequences. ACKNOWLEDGMENTS
The author wishes to thank Drs. Charles Abottsmith and Richard Henthorn for their review of the manuscript and Beverly Lohr for her secretarial assistance. REFERENCES 1 . Cowley MJ, Doms G , Kelsey SF, VanRaden M, Detre K: Acute coronary events associated with percutaneous transluminal coronary angioplasty. Am J Cardiol 53:12C-I6C,1984. 2. Grewe K, Presti C, Perez JA: Torsion of the internal mammary graft during PTCA: A case report. Cathet Cardiovasc Diagn 19: 195-197, 1990. 3. Tenaglia AN, Tcheng JE, Phillip HR, Stack R: Creation of pseudonarrowing during coronary angioplasty. Am J Cardiol 67:658-
659, 1991. 4. Rauh RA, Ninneman RW, Joseph D, Gupta VK, Senin DG,Miller W: Accordion effect in tortuous right coronary arteries during percutaneous transluminal coronary angioplasty. Cathet Cardiovasc Diagn 23:107-110,1991. 5. Angelini P: “Balloon Catheter Coronary Anpioplasty.” New Yoik: Future Publishing Co., 1987, pp 135-142: ~
Mechanical Coronary Artery lnvagination 6. Waller B F 'Crackers, breakers, stretches, drillers, scrapers, shav-
ers, burners, welders and melters.' The future treatment of atherosclerotic coronary artery disease? A clinical morphologic assessment. J Am Coll Cardiol 13:969-987, 1984. 7. Spears JR, Reyes VP,Wynne J, et al.: Percutaneous coronary laser
139
balloon angioplasty: Initial results of a multicenter experience. J Am Coll Cardiol 16:293-303, 1990. 8. Shatz RA: A view of vascular stents. Circulation 79:445-457, 1989.
