APCU25CR25 Percutaneous coronary intervention to LMS-LAD after ostial LAD dissection from JL 3.5 guiding catheter in high risk NSTEMI

Introduction Catheter induced coronary artery dissection is rare but potential life-threatening complication during percutaneous coronary intervention (PCI). It commonly occurs during emergency procedure. Small ostial diameter or tight atheroma, forceful and deep catheter insertion, catheter malalignment, repetitive and wedged contrast injection was reported among the common cause. We present a case of Judkin left (JL) guide catheter induced ostial left anterior descending (LAD) dissection during emergency PCI.Case Presentation A 60 yrs old gentleman admitted with non-ST elevated myocardial infarct (NTEMI). Diagnostic angiogram via standard right radial showed severe focal stenosis at osteo-proximal LAD. JL 6Fr guide catheter with a sion blue advanced to left circumflex artery (LCX) for better support. Initial attempt with a run through floppy (RTF) wire and 1.5 x 15 mm balloon support failed to cross the proximal LAD stenosis. Further aggressive attempts complicated with ostial LAD dissection and occluded LAD flow. Finecross microcatheter support and multi wire escalation were unsuccessful. Meanwhile patient developed chest pain and became hemodynamically unstable. JL guide-catheter changed to EBU 3.5 and Fielder-XT wire with Supercross microcatheter (90 0) successfully crossed the lesion and stented from left main (LM) until proximal LAD after predilation with 4.0x33mm and 3.5x23 mm at mid LAD. Proximal LAD post dilated with NC 4.5x15 mm balloon (sub-nominal) and proximal optimisation (POT) of LM stent with NC 4.5x15 mm (high pressure). Final angiogram showed good result.Discussion Iatrogenic catheter induced dissection during invasive coronary artery procedure is very rare and reported