LIMA Stenting Through a Left Radial Approach After PCI of an LAD Through a LIMA Caused a Severe Dissection

Using the left radial approach a 6Fr JL 3.5 guiding catheter, and a BMW guidewire, the lesion in the ramus was crossed and predilated using a 1.5x10mm Sapphire balloon. The target lesion was stented using a 2.25x18mm Euca Tax stent (PES, Germnay) at 14atm to achieve TIMI III flow (Figure 5, Figure 6). Then a 5Fr JR guiding catheter was used to cannulate the LIMA. A BMW guidewire was chosen to cross the LAD lesion through the LIMA. Due to the tortuosity of the LIMA, this required support with a 2x9mm Maverick balloon after which the target lesion was predilated at 12atm. Then an attempt was made to deploy a 2.5x12mm Optima stent (CID, Italy), but it was very difficult even using “buddy wiring” technique. Deep intubation of the guiding catheter was required to position the stent that was then implanted at 16atm (Figure 7, Figure 8). After the guiding catheter and guidewire were withdrawn, there was no flow to the LIMA (Figure 9). After rewiring, a long segment of intimal dissection in the LIMA was observed (Figure 10). Therefore, two bare metal stents (3x23mm STS Flex and 3x18mm R stent) were deployed into the LIMA overlapping each other (Figure 11, Figure 12). Distal TIMI III flow was achieved.