Edge Dissection Post Stent Deployment?
A 65-year-old Caucasian female with past medical history significant for hypertension and a 47-pack-per-year smoking history presented to the hospital with an inferior ST-segment elevation myocardial infarction (STEMI). Coronary angiography revealed a thrombotic occlusion of the proximal right coronary artery (RCA) and 60% stenosis of the first obtuse marginal branch. Following balloon angioplasty, flow was successfully restored to the RCA, but the patient developed cardiogenic shock with bradycardia necessitating atropine and vasopressors with intra-aortic balloon pump support. After deployment of overlapping stents to the proximal and mid RCA, there was concern for dissection at the proximal as well as the distal stent edges. The patient underwent stenting of the RCA to the ostium, and a stent was deployed at the distal edge with restoration of Thrombolysis in Myocardial Infarction (TIMI) 3 flow. The patient was discharged home several days later with optimal medical therapy after an uneventful post-procedure course.
Six months later, she underwent a nuclear stress test due to progressive dyspnea on exertion, which revealed significant lateral ischemia and normal left ventricular function. She was subsequently referred for repeat coronary angiography, which revealed patent stents in the RCA and a focal 95% stenosis of the proximal portion of the obtuse marginal branch of the left circumflex artery (Figure 1 and Video 1). The first obtuse marginal lesion was then treated with balloon angioplasty using a 2.0 x 10 mm balloon with resultant TIMI 3 flow and good vessel expansion followed by subsequent placement of a 2.25 x 12 mm drug-eluting stent. After deployment of the stent, there was concern for coronary dissection distal to the stent, which persisted after a dose of 200 mcg of intra-coronary nitroglycerin (Figure 2 and Video 2). Despite some new chest pressure, the patient was hemodynamically stable with well-maintained blood pressures (130s/80s).
What should the next step be in the management to restore flow distal to the stent?