Acute failure of cutting balloon fenestration in spontaneous coronary artery dissection

We present the case of a 42-year-old woman admitted due to ST-segment elevation acute coronary syndrome. The coronary angiography revealed the presence of an occluded mid-distal left anterior descending coronary artery (LAD) (figure 1A, asterisk) with an image suggestive of intramural hematoma (IMH) consistent with spontaneous coronary artery dissection (figure 1A, arrow). Guidewires were passed through the distal and diagonal LAD that resulted in flow recovery (figure 1B, line and arrowheads outlining the IMH). The intravascular ultrasound (IVUS) confirmed the presence of a large 25 cm long IMH (figure 2A,D). After dilatation with a 2.0 mm/6 mm cutting balloon (Wolverine, Boston Scientific, United States) (figure 1C, asterisks) flow improved leaving a mild residual stenosis (figure 1D). After a few minutes the retention of contrast in the LAD was confirmed (figure 3A, ellipse) followed by ischemic changes on the electrocardiogram. The angiography revealed the presence of 2 regions of critical stenosis with aggravated distal flow abnormalities (figure 3B, lines outlining the IMH, arrowheads showing the stenotic regions). A 2.25 mm/33 mm drug-eluting stent was implanted (Ultimaster Tansei, Terumo, Japan) (figure 3C, asterisks) and later dilated up to 2.75 mm with excellent angiographic (figure 3D) and IVUS results (figure 2E,F). The entire...