S250 J O U R N A L O F T H E A M E R I C A N C O L L E G E O F C A R D I O L O G Y , V O L . 6 7 , N O . 1 6 , S U P P L S , 2 0 1 6

Case Summary. Dealing with heavy calcified lesion is challenging andneeds proper technique to overcome. Sometimes we may need Motherand Child system in dealing the difficulty to deliver the stent. Catheterinduced coronary dissection during PCI is a rare complication but lifethreatening especially in unprotected coronary artery which supplyother disease vessel. Manipulation of child catheter may createdissection. Careful selection and manipulation of catheters andpaying more attention to high-risk lesion are important to avoid suchcomplication. Prompt treatment with conventional stenting for coro-nary dissection is essential and lifesaving.

TCTAP C-130Retrieval of Broken Diagnostic Coronary Catheter Using AngioplastyBalloon

Saurabh Goel11Cumballa Hill Hospital, India

[CLINICAL INFORMATION]Patient initials or identifier number. SARelevant clinical history and physical exam. 50 year old male patient,hypertensive since 3 years, non-diabetic, nonsmoker recent history ofhospitalization 8 days back for acute chest pain and treatment asacute inferior myocardial infarction. He was thrombolysed with ten-ecteplase pulse 66/min bp 150/86 cvs - nad rs – clear.Relevant catheterization findings. Coronary angiography was done fromright femoral access. The LAD showed 50% proximal lesion andLCxwas dominant and normal. The RCA was arising anamously fromhigh midlineorigin and could not be cannulated despite using severalstandard catheters. Anattempt was made using al1 catheter as it wasthought that it may reach theorigin. But during manipulation thedistal tip of about 4cm broke from theshaft and migrated to upperthoracic aorta.[INTERVENTIONAL MANAGEMENT]Procedural step. Retreival of the catheter piece was attempted usingavailable loop basket snare but it unsuccessful.Right angle loop snarewas not available at that time in the cath lab. Punchbiopsy forcep wasthen used which gripped the shaft of the catheter piece andthe distalcurved part of the amplatz catheter was removed. During themani-pulation, a small 1.5 cm part of the shaft proximal to the point ofat-tachment of the forcep broke and migrated into a branch of thefemoralartery. The left femoral artery was then punctured andthrough a cross over sheath. A multipurpose guiding was placed nearthe catheterpiece. Two coronary guide wires (0.0014) were passedthrough the lumen of thecatheter piece. On one of the wires a2x10 mm angioplasty balloon was placed atthe centre of the catheterpiece. It was inflated to 16 atm and the piece wassecured and

withdrawn into the guiding catheter with traction of both wires and-successfully brought out and the small piece was also retrieved.

J O U R N A L O F T H E A M E R I C A N C O L L E G E O F C A R D I O L O G Y , V O L . 6 7 , N O . 1 6 , S U P P L S , 2 0 1 6 S251

Case Summary. A broken catheter piece in the arterial system isnightmare in the cath lab and requires out of the box thinking forretreival. In this case the broken piece was partly removedwith apunch biopsy forcep. Another smaller piece migrated to a smallerdistalartery where thrombus formation was possible and surgicalremoval would havebeen very difficult. An innovative strategy of twocoronary guide wires and angioplastyballoon inflated in the lumen ofthe piece was used to successfully remove thebroken catheter.

TCTAP C-131Iatrogenic Dissection of Right Coronary Artery Concomitant withAntegrade Aortic Dissection

Chun-Yen Chiang,1 Po-Sen Huang,1 Chen-Chuan Cheng,1 Po-Ming Ku1

1Chi-Mei Medical Center, Taiwan

[CLINICAL INFORMATION]Patient initials or identifier number. 10854785 Mrs. LiRelevant clinical history and physical exam. This 71 years old female withobese figure suffered from crescent chest tightness since yesterday.She has the medical history of hypertension and diabetes mellituswith poor control (HbA1C 9.0%). She reported the discomfort was dullpain, persisted for more than 10minutes and accompanied diaphoresisand dyspnea but no radiation. This angina was partially relieved byresting and nitroglycerin 1 tab sublinqual use. Physical exam revealedno heart murmur or rales over chest.Relevant test results prior to catheterization. No dynamic elevation ofcardiac enzyme in 4 hours was noticed. Serial ECG showed atrialfibrillation with moderate ventricular response and no2015 obvious orsignificant ST-T change was noted.

Reference

hs-Troponin<26.2 pg/mL CK-Total29-168

U/L

CK-MBmass <3.4 ng/mL

2015/09/06 ER

hs-TroponinI[3.40 pg/mL] CK-Total[44U/L] CK-MBmass[0.7 ng/mL]

4 hours later

hs-TroponinI[4.20 pg/mL] CK-Total[49U/L] CK-MBmass[0.8 ng/mL]

Relevant catheterization findings. Post-Cath Diagnosis: CAD (1-V-D) overRCA with iatrogenic spiral dissection extending to ascending aorta.Engaging catheter: RCA: JR4.0; LCA: JL3.5Dominant: RCALM: NormalLAD: NormalLCX: NormalRCA: Spiraldissection involved aortic root with contrast stasis and

RCA-ostiun to RCA-D with TIMI II when engaged into RCA-ostium byguiding catheter of JR4(Boston). The 12-leadECG showed ST elevationand the patient felt chest pain with radiation to back. Meanwhile, BP150/84mmHg, HR: 65 bpm and SPO2: 95%.[INTERVENTIONAL MANAGEMENT]Procedural step. Due to bradycardia and hypotension, we depositedtemporary pacemaker and the condition became relatively stable.Later, we finished left coronary angiography, which showed no lesion.Under the guiding catheter of JR4.0, 6Fr(Bosten) via left radial

approach, the first guidewire(GW) of Fielder(Asahi) cross RCA-lesionsmoothly and then we put the IVUS into RCA-D and showed GW intofalse lumen from RCA-O to RCA-D. We decided to put another GW ofFilder into RCA again. Finally, IVUS showed second GW in true lumen.The inlet was in RCA-O near aortic root and RCA-dissection withextension to RCA-D. The IVUS also revealed lumen size was 4.0 to5.0 mm. Then we deployed bare-metal stent sequentially from RCA-Dto RCA-ostium. In the end, IVUS showed stent well apposed over thevessel from RCA-D to RCA-O.About the dissection of ascending aorta, we consulted CV surgeon

and he suggested CT angiography after management of RCA dissec-tion by PCI. After CTA, the surgeon suggested observation first andsurgery would be done if hemodynamics change or poor healing in thefollowing.