Coronary Sinus of Valsalva Dissection and Acute Stent Thrombosis Resulting From a Balloon Rupture

Abstract

We present the case of a retrograde dissection of a right coronary artery (RCA) into the coronary sinus of Valsalva (CSV) attributed to a high-pressure jet extruding from a ruptured angioplasty balloon. The dissection was further complicated by an acute stent thrombosis. Both the CSV dissection and the acute stent thrombosis were successfully treated percutaneously using a combination of a Jo-Med Covered Stent and three bare metal stents. Case PresentationAn 83-year-old female developed chest pain and shortness of breath on postoperative day 3 after a total knee replacement. Her electrocardiogram revealed new-onset atrial fibrillation with a rapid ventricular rate and inferolateral ST segment depressions. She was treated with intravenous metoprolol for rate control and spontaneously converted to normal sinus rhythm after a few hours. She ruled in for a myocardial infarction with mildly positive Troponin I of 0.09 ng/dL. Her spiral computed tomography scan was negative for pulmonary emboli. The patient had a nuclear stress test that revealed inferior ischemia, and she was referred for coronary angiography.The patient's left coronary system revealed no significant disease, but her RCA coronary had an 80% to 90% stenosis in the ostial portion, followed by a 70% to 80% stenosis in the proximal vessel and a 40% to 50% stenosis in the mid vessel. The 4-French catheter dampened with each engagement of the RCA. The ostium of the RCA was calcified and highly angulated (Figures 1 and 2). Because of the patient's high-risk clinical and angiographic presentation, she was referred for a percutaneous coronary intervention (PCI).A 6-F JR4 Cordis guiding catheter was placed near the ostium of the RCA, which could not be engaged due to damping. A .014-in. PT2 wire was manipulated past the RCA lesions into the distal posterior descending coronary artery. The ostial and proximal RCA lesions were predilated with a 2.5 mm × 12 mm Sprinter balloon to 8 atm. A 70% to 80% residual stenosis remained in the ostial lesion, with a 60% to 70% residual in the proximal lesion; therefore, provisional stenting was employed. Because of the patient's advanced age, atrial fibrillation, and history of gastrointestinal bleeding, we decided to use overlapping bare metal stents. A 3.0 mm × 20 mm Liberte stent was deployed in the proximal RCA at 12 atm, and a second 3.0 mm × 20 mm Liberte stent was deployed at 14 atm in the proximal portion of the first stent, extending 2 to 3 mm out of the ostium of the RCA (Figure 3). A 3.0 mm × 15 mm Quantum Maverick balloon was used for high-pressure postdilatation. The Quantum Maverick was first inflated to 16 atm in the distal stent and then inflated to 16 atm in the ostial stent. After these first two inflations, no contrast was seen in the CSV (Figure 4). A third inflation to 14 atm was performed with the Quantum Maverick extending outside the ostial stent, in order to ensure the ostium was fully dilated. During this third inflation, the balloon was noted to lose pressure at approximately 14 atm, and was quickly...