|Year : 2016 | Volume
| Issue : 3 | Page : 108-109
Missing left main ostio-proximal coronary artery disease during angiography using tiger catheter
Biswajit Majumder, Viral Tandel
Department of Interventional Cardiology, R. G. Kar Medical College, Kolkata, West Bengal, India
|Date of Web Publication||16-Sep-2016|
Department of Interventional Cardiology, R. G. Kar Medical College, Kolkata, West Bengal
Source of Support: None, Conflict of Interest: None
Coronary angiography by right radial artery route using Optitorque Tiger catheter is on the rise given the low rate of local complications and feasibility to perform it as a day-care procedure. We report here a case of coronary angiography performed using Optitorque Tiger catheter (5-French) which resulted in a diagnostic error, missing the ostio-proximal left main coronary artery disease which was later detected using EBU 3.5 guide catheter (7-French) while performing angioplasty.
Keywords: Coronary angiogram, optitorque Tiger catheter, ostio-proximal left main coronary artery disease
|How to cite this article:|
Majumder B, Tandel V. Missing left main ostio-proximal coronary artery disease during angiography using tiger catheter. Heart India 2016;4:108-9
|How to cite this URL:|
Majumder B, Tandel V. Missing left main ostio-proximal coronary artery disease during angiography using tiger catheter. Heart India [serial online] 2016 [cited 2019 Mar 24];4:108-9. Available from: http://www.heartindia.net/text.asp?2016/4/3/108/190747
| Introduction|| |
With increase in global cardiovascular disease burden, there has also been an increase in the diagnostic and therapeutic interventions to deal with this increased demand. The vascular site access option for coronary angiography and angioplasty that is a femoral artery or radial artery route has their own advantages and disadvantages. The radial approach is an appealing technical strategy to reduce the bleeding complications when compared to femoral route and potentially increase the n2umber of an outpatient procedure. We here report a diagnostic error of missing the ostio-proximal left main coronary artery (LMCA) disease while performing coronary angiogram using Optitorque Tiger catheter of 5-French size.
| Case report|| |
A 46-year-old female, known diabetic and hypertensive for 4 years came to the outpatient department with the complaint of exertional angina on guideline determined medical therapy.
On examination, her pulse was 76/min; blood pressure was 142/84 mmHg, and cardiovascular system examination did not reveal any abnormal findings. Her electrocardiogram showed left ventricular hypertrophy. Echocardiographic examination showed concentric left ventricular hypertrophy, with no regional wall motion abnormalities.
She was counseled for coronary angiography, and after written informed consent was taken for the procedure. Coronary angiogram was performed by right radial artery route under local anesthesia by using diagnostic 5-French Optitorque Tiger catheter. It showed: Normal LMCA, 80% disease in mid part of left anterior descending artery, a significant ostio-proximal second diagonal disease with minor disease in the right coronary artery and circumflex artery.
Because of bifurcation disease, we decided to proceed for angioplasty by femoral artery route. After the introduction of 7-French arterial sheath, LMCA was engaged by 7-French EBU 3.5 guide catheter. Due to pressure damping and suspecting coronary artery ostial spasm guide catheter was disengaged. After few minutes catheter was re-engaged and injection nicorandil and nitroglycerine was given by intracoronary route. Check angiogram revealed significant narrowing of ostio-proximal part of LMCA. We waited for another 5-6 min and again injection nicorandil and nitroglycerine was given and check angiogram was taken which revealed 50-60% narrowing of the ostium and proximal LMCA [Figure 1].
|Figure 1: Coronary angiogram-right caudal view showing: (a) Missing of ostio-proximal left main coronary artery disease by 5-French Tiger catheter. (b) Which was later detected by 7-French EBU guide catheter while performing angioplasty|
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The angiogram taken by radial artery route was revised. Which showed the possibility of ostio-proximal disease in the right caudal view; which was missed while interpreting angiography report [Figure 2].
|Figure 2: (a and b) Coronary angiogram-right caudal view performed by 5-French Tiger catheter. Showing narrowing of the segment of left main coronary artery extending from ostium to tip of Tiger catheter (marked by black arrow)|
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The patient was stable during the procedure. The patient was given the option for coronary artery bypass grafting and was referred to a cardiovascular surgeon for coronary artery bypass surgery.
| Discussion|| |
A lot of diagnostic coronary procedures are performed by radial artery route; offering the benefit of performing the procedure as a day care procedure with a low incidence of local site complications compared to the traditional transfemoral route.
Restricting my discussion for diagnosing LMCA disease by 5-French Optitorque Tiger catheter, we have found that LMCA with significant disease might be missed.
Significant LMCA disease, defined as 50% narrowing of LMCA diameter is found in 4-6% of all patients who undergo coronary angiography.  Most of the patients are symptomatic and are at high risk of cardiovascular events unless protected by collaterals or a patent bypass to left anterior descending or circumflex. The normal LMCA diameter is around 4.5 ± 0.5 mm 2 .  In Indian population, the diameter is 3.72 mm in males and 3.40 mm in females.  Hence, Optitorque Tiger catheter of 5-French (1.70 mm) can enter and deep engage ostial disease LMCA. Taking an angiographic view in this situation can sometimes miss the ostio-proximal disease as was in our case.
Angiographic view for LMCA; anterior-posterior view and spider view, taken while simultaneously withdrawing the Tiger catheter and injecting the dye might help to diagnose the ostio-proximal LMCA disease which could be missed.
Ostio-proximal part of LMCA should be visualized in several projections while performing angiogram using Optitorque Tiger catheter, particularly that segment of LMCA which extends from coronary ostium up to the tip of Tiger catheter [Figure 2].
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Ragosta M, Dee S, Sarembock IJ, Lipson LC, Gimple LW, Powers ER. Prevalence of unfavorable angiographic characteristics for percutaneous intervention in patients with unprotected left main coronary artery disease. Catheter Cardiovasc Interv 2006;68:357-62.
Dodge JT Jr., Brown BG, Bolson EL, Dodge HT. Lumen diameter of normal human coronary arteries. Influence of age, sex, anatomic variation, and left ventricular hypertrophy or dilation. Circulation 1992;86:232-46.
Saikrishna C, Talwar S, Gulati G, Sampath Kumar A. Normal coronary artery dimensions in Indians. IJTCVS 2006;22:159-64.
[Figure 1], [Figure 2]