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 . 7 1 , N O . 1 6 , S U P P L S , 2 0 1 8 S175

Conclusions. In this case we sealed coronary fistula with coiling pro-cedure. Despite not visualizing any obvious perforation, we passed amicrocatheter into the false lumen to find the source of perforation.We also managed coronary perforation by use of ‘fat embolism’

technique which is unique and not commonly used. We staged PCI toCTO LAD at a later date and successfully crossed the lesion. We usedTAP for bifurcation technique. We also used ‘POT’ technique to opti-mize flow to the diagonal artery.This patient was well post procedure and discharged the following

day.

TCTAP C-106

An Interventionalists’ Nightmare: Iatrogenic Aortic Dissectionfrom Left Main Coronary Artery

Ching-Chang Huang,1 Chun Kai Chen1

1National Taiwan University Hospital, Taiwan

CLINICAL INFORMATION

Patient Initials or Identifier Number. HMCRelevant Clinical History and Physical Exam. This a 65-year-old femalecomplained of intermittent chest tightness for one year.Her CAD risk factors included age, hypertension and family history

of premature CAD. (Her brother died of MI)The thallium scan showed significant stress induced ischemia at

apical myocardium, inferolateral, and mid to basal inferior walls.She was admitted for coronary intervention.

Relevant Test Results Prior to Catheterization. -EKG: Normal sinusrhythm, with non-specific ST-T change-Thallium scan:Under standardized dipyridamole stress test, (1) significant stress

induced ischemia at apical myocardium (mixed with subendocardialscar at apical lateral wall), inferolateral, and mid to basal inferiorwalls, (2) good LV systolic function, but suspicious of stress inducedLV dysfunction.Relevant Catheterization Findings. -LM: Shaft stenosis 50 %, calcified-LAD: Proximal stenosis 70 %, calcifiedMiddle 99% stenosis-LCX: Patent, with collateral to RCA-RCA: Proximal stenosis 90 %Distal stenosis 90 %With collateral to LAD

INTERVENTIONAL MANAGEMENT

Procedural Step. CABG and PCI were discussed with patient and PCIwas chosen. LAD was fixed first after reviewing the collateral arterydistribution. The critical LAD lesion was passed by ASAHI Fielder XTA190 cm under the guiding catheter of Medtronic EBU 3.5 7F. The IVUS

S176 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 . 7 1 , N O . 1 6 , S U P P L S , 2 0 1 8

was checked for vessel size measurement. Pre-dilatation was per-formed to mid-LAD.A DES was introduced. A final contrast injection was done for po-

sition confirmation. However, acute ascending aortic dissection fromleft main coronary artery, accompanied with seizure and VF, devel-oped. Electric cardioversion was done twice and dopamine was givenfor low BP. The patient became clear and the BP elevated.Due to high inotropics requirement, immediate LM-LAD stenting to

seal the flap was decided, rather than awaiting emergent operation. Adouble-channel microcatheter was introduced through LAD wire.(Kaneka CRUSADE) LCX wiring with ASAHI SION through the sideholeof CRUSADE was done for protection. The 1st DES was deployed atmLAD. (Abbott Xience Xpedition 2.5 mm * 48 mm) No more contrastwas injected. The LM ostium was localized by IVUS. A DES wasdeployed from LM-ositum to pLAD. (Abbott Xience Xpedition 3 mm *33mm) The final LCA angiogram showed adequate LM-LAD flow andthe ascending aortic dissection was not progressed. The patient wasdischarged 2 days later.Three months later, the CT showed healed dissection. The LCA flow

was good. Two DES were deployed to RCA. (Boston SYNERGY 2.5 mm* 32 mm; ORSIRO 3.0 mm * 40 mm)

Conclusions. [Take Home Message]-Every basic step in coronary intervention was crucial.*Avoid acute intercept angle between guiding catheter and coronary

vessels.-Iatrogenic aortic dissection from coronary arteries was a rare but

life threatening complication. It should be managed carefully andpromptly.*The strategies were associated to the dissection mechanism, the

extent of dissection and the patient’s hemodynamics.

TCTAP C-107

No Reflow After Stent Deployment, How Should We Do?

Wei Da Lu1

1National Cheng Kung University Hospital, Taiwan

CLINICAL INFORMATION

Patient Initials or Identifier Number. Mr. O.Relevant Clinical History and Physical Exam. Mr. Ou, 50 y/o maleadmitted for operation of abdominal aorta aneurysmHe received per-OP coronary angiographyHis underlying disease included hypertension, smoking, DMThe baseline ADL function for the patient is independent.

Relevant Test Results Prior to Catheterization. EKG: sinus rhythm withoutST segment changeCT: Diffuse aortomegaly with multifocal ulcerated mural atheromas,

stationarya) Distal arch aneurysm, 3.4 cmb) Infrarenal abdominal aortic aneurysm, 5.5cmc) Bilateral common femoral artery aneurysm, R:1.8 cm & L: 1.8츠

Relevant Catheterization Findings. NilINTERVENTIONAL MANAGEMENT

Procedural Step. Left Main: Atherosclerosis without significantstenosisLAD: Atherosclerosis with 80% stenosis at middle part, 60% stenosis

at D-1,70% stenosis at intermediate vesselLCX: Atherosclerosis with 70% stenosis at distal partRCA: Atherosclerosis with 80% stenosis at proximal part, 60% ste-

nosis at distal part1. We used a EBU4.0 SH guiding catheter to engage LCA orifice.2. The Runthrough extra floppy wire to distal LAD.3. A Hiryu balloon (3.0/15 mm) to dilate mLAD with 12 bars.4. "Ultimaster" stent (3.0/38 mm) deployed at mLAD followed by

Hiryu balloon (3.5/20 mm), however, the vessel lumen beneath thestent became smaller and blood flow got slower. The IMH orsp asmwas suspected.5. We then used IVUS and confirmed the IMH and inlet was around

distal part of stent.6. The cutting balloon (2.75/15mm) was used for cutting at distal

part several times, the following IVUS showed extravasation shrinked.7. The distal part of LAD flow was compromised. We then used

crisade microcatheter to digital part and test contast which showedcompromised by IMH.8. The second day cutting was done, and we deployed Omega stent

(2.75/12 mm) beneath the stent.9. The final angiography showed TIMI 2-3flow with multiple cutting

site.