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Chapter 28. Coronary Balloon Angioplasty

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A 62-year-old woman taking oral hypoglycemic agents for known diabetes presents with a 2-h history of retrosternal chest pain and nausea to an emergency department without a cardiac catheterization laboratory. On presentation, she did not appear to be in any distress. Her vital signs: BP 135/88 mm Hg, HR 90/mn regular, respiratory rate 18/minute, and she was afebrile. Her ECG is shown in Figure 1. She was started on anti-platelets and anti-thrombotic agents and was transferred to the cardiac catheterization laboratory where angiographic images showed a small area of inferior akinesis and a non-dominant right coronary artery. The left system is shown in Figure 2. The totally occluded second obtuse marginal was pre-dilated then stented with a 2.75 × 23 mm drug-eluting stent. The angiogram taken after stent deployment is shown in Figure 3. The interventional cardiologist administers intracoronary nitroglycerin without appreciable improvement in the lesion distal to the stent. At this point the most appropriate next step is to:

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Figure 1

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Figure 2

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Figure 3

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A. Dilate the lesion distal to the stent with a 2.0 mm non-compliant balloon.

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B. Directly stent the lesion distal to the stent with a 2.25 mm × 12 mm drug-eluting stent.

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C. Withdraw the wire and obtain a coronary angiogram.

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D. Use a thrombus aspiration catheter.

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The correct answer is C

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New unexpected lesions in the course of a coronary intervention should raise the suspicion of a pseudo-lesion. The clue is moderate-to-severe coronary tortuosity at baseline before introducing the guidewire. Pseudo-lesion is the result of straightening of a tortuous coronary artery over the stiff part of the guidewire. It is also referred to as pseudo-narrowing or accordion effect. The differential diagnosis includes spasm, a coronary dissection and thrombus formation/embolization. But if a pseudo-lesion is not suspected or considered in the differential diagnosis, unnecessary interventions may take place, possibly subjecting the patient to inadvertent complications. Pseudo-lesions can be severe and can cause total obstruction of coronary flow with resultant chest pain and electrocardiogram changes. When suspected, the guidewire may be withdrawn while keeping the soft part across the suspected lesion. The soft part of the wire will cause less straightening, therefore improving the angiographic appearance of the pseudo-lesion. In case this is not confirmed, the wire can be safely re-advanced since it is already across the lesion. Figure 5 shows the angiographic appearance of the artery after withdrawing the wire.

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Figure 5

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A 57-year-old man presented with ...

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