SS–24 From Cardiac Arrest to Successful LMCA Bifurcation PCI: A Challenging Case

Abstract

Introduction and Aim: Iatrogenic coronary dissection with cardiac arrest is a rare but life-threatening complication of percutaneous coronary intervention, particularly in patients with complex coronary anatomy. We present a challenging case of ostial LCx dissection complicated by cardiac arrest in a patient with NSTEMI, diabetes mellitus, and chronic kidney disease. Following successful resuscitation and stabilization, the patient underwent complex LMCA-LAD-LCx bifurcation PCI with sequential stenting, proximal optimization, and kissing balloon techniques, resulting in complete sealing of the dissection and restoration of TIMI grade 3 flow. This case highlights the importance of meticulous guidewire control and a systematic, stepwise approach to complex bifurcation PCI in the management of iatrogenic coronary dissection. In patients with diabetes mellitus and chronic kidney disease presenting with NSTEMI, coronary anatomy is often complex, heavily calcified, and technically challenging. Iatrogenic subintimal dissections occurring during percutaneous coronary interventions (PCI), particularly when complicated by hemodynamic arrest, represent highly challenging clinical scenarios associated with substantial morbidity and mortality. We aimed to present a case of cardiac arrest following subintimal wire passage during intervention for an ostial circumflex (LCx) lesion at an outside center, followed by successful complex left main coronary artery–left anterior descending artery–left circumflex (LMCA-LAD-LCx) bifurcation stenting after referral to our center following intensive care unit management.

Case Report: A 66-year-old man with known diabetes mellitus (DM) and chronic kidney disease (CKD) presented to an outside center with chest pain and was diagnosed with NSTEMI. Coronary angiography (CAG) revealed 99% stenosis at the ostium of the LCx. During an attempt to cross the lesion with a guidewire, the wire entered the subintimal space, resulting in coronary dissection and cardiac arrest on the angiography table. Following approximately 15 minutes of cardiopulmonary resuscitation (CPR), sinus rhythm was restored. The patient was subsequently monitored in the intensive care unit for 5 days and then referred to our center for further evaluation and treatment. After hemodynamic stabilization at our center, the patient was transferred to the catheterization laboratory. Following successful cannulation of the left main coronary artery (LMCA), 0.014-inch guidewires were successfully advanced separately into the LAD and LCx. Predilatation of the 99% ostial LCx lesion was performed using a 3.0×15 mm PTCA balloon at 18 atm. Subsequently, a 4.0×24 mm drug-eluting stent (DES) was deployed from the LCx into the LMCA at 14 atm, followed by proximal optimization technique (POT) using a 5.0×8 mm non-compliant (NC) balloon in the LMCA. After rewiring the LAD, kissing balloon inflation was performed using a 3.0×15 mm balloon in the LAD and a 3.5×15 mm balloon in the LCx. Subsequently, a 4.0×33 mm DES was deployed from the LAD into the LMCA at 18 atm, followed by repeat POT in the LMCA using a 5.0×8 mm NC balloon. The distal LCx was rewired, and final kissing balloon inflation was successfully performed using a 3.0×15 mm NC balloon in the LCx and a 3.5×15 mm NC balloon in the LAD. The procedure was completed with a final POT of the LMCA using a 5.0×8 mm NC balloon. Post-procedural control coronary angiography demonstrated excellent bifurcation anatomy and optimal stent expansion, with TIMI grade 3 flow in both the LAD and LCx. The dissection plane was completely sealed. The patient had an uneventful clinical and hemodynamic course and was discharged in good clinical condition.

Conclusion: In high-risk and anatomically challenging cases complicated by iatrogenic coronary dissection and cardiac arrest, experienced and systematic complex PCI strategies following acute-phase stabilization can be lifesaving. This case demonstrates that even in subintimal dissection involving the left main coronary artery and major branches, excellent angiographic and clinical outcomes can be achieved through meticulous guidewire control, optimal balloon and stent sizing, and repeated POT– kissing balloon inflation techniques.