Utilization of a double-wire technique to treat long extended spiral dissection of the right coronary artery. Evaluation of incidence and mechanisms.

While coronary artery dissection caused by a guiding catheter, which is one of the most commonly occurring complications during diagnostic cardiac catheterization or coronary intervention, has various forms, extensive antegrade and retrograde dissections of the right coronary artery (RCA) are rarely observed during these procedures. Within the last three years, we retrospectively reviewed our experience with 12,600 consecutive patients who underwent either diagnostic cardiac catheterization or coronary angioplasty, and found that 17 (0.14%) of the patients displayed extensive antegrade and retrograde RCA dissection. The antegrade dissection always propagated to the distal RCA either on bifurcation of the posterior descending artery and posterolateral artery (PLA) or to the proximal PLA. The retrograde dissection was always observed close to the ostium of the RCA or extending to the ostium of the RCA. TIMI-0 flow in the RCA was immediately observed in all the patients. Chest pain associated with an electrocardiogram showing ST-segment elevation was soon observed in most of the patients. The true lumen could be entered successfully using a single wire in 8 of 17 patients. However, a double-wire technique was required for 7 patients. This technique involved first advancing a wire along to the false lumen and then pulling back the guiding catheter away from the ostium of the RCA for a few millimeters followed by anchoring with the wire. Another wire was then gently inserted into the true lumen from the dissection entrance point, which was located near or at the ostium of RCA, and carefully advanced to the distal RCA. Coronary stenting was successfully deployed in 15 patients. However, the procedure failed in 2 patients. Furthermore, this complication caused 7 patients to have acute myocardial infarctions, 2 patients to develop atrial fibrillation, and I to die from ischemic enterocolitis due to cardiac embolism after 7 months of follow-up. In conclusion, with an increase in experience, we now better understand this complication. However, this complication, which is a formidable challenge for coronary intervention, may be a life-threatening complication, and patients with this complication may face the potential risk of a nonfatal myocardial infarction, or even a long-term fatal outcome in the long-term. Accordingly, it is important to learn how to promptly manage this complication.