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\begin{document}

\title{Successful revascularization with percutaneous coronary intervention
using a combination of the subintimal transcatheter withdrawal technique
and coronary artery fenestration for spontaneous coronary artery
dissection}



\author[1]{Shintaro Matsuura}%
\author[1]{Kanichi Otowa}%
\author[1]{Michiro Maruyama}%
\author[1]{Kazuo Usuda}%
\affil[1]{Toyama Prefectural Central Hospital}%


\vspace{-1em}



  
  \date{June 05, 2024}


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\selectlanguage{english}
\begin{abstract}
We present a case of successful revascularization for spontaneous
coronary artery dissection (SCAD) using coronary artery fenestration
followed by the subintimal transcatheter withdrawal (STRAW) technique.
The combination of the STRAW technique and coronary artery fenestration
with cutting balloon angioplasty could be a new treatment option for
SCAD patients requiring revascularization.%
\end{abstract}%



\sloppy


Successful revascularization with percutaneous coronary intervention
using a combination of the subintimal transcatheter withdrawal technique
and coronary artery fenestration for spontaneous coronary artery
dissection

Shintaro Matsuura, MD; Kanichi Otowa, MD, PhD; Michiro Maruyama, MD,
PhD; Kazuo Usuda, MD, PhD

Department of Cardiology, Toyama Prefectural Central Hospital, Toyama,
Japan

Shintaro Matsuura, Department of Cardiology, Toyama Prefectural Central
Hospital, Toyama, 2-2-78 Nishinagae, Toyama-shi, Toyama-ken 930-8550,
Japan.

E-mail address:\emph{mat.s.86m23@gmail.com}

Word count: 1984 words

ABSTRACT

We present a case of successful revascularization for spontaneous
coronary artery dissection (SCAD) using coronary artery fenestration
followed by subintimal transcatheter withdrawal (STRAW) technique. The
combination of the STRAW technique and coronary artery fenestration with
cutting balloon angioplasty could be a new treatment option for SCAD
patients requiring revascularization.

KEY CLINICAL MESSAGE

The combination of the STRAW technique and coronary artery fenestration
using a cutting balloon could be effective in SCAD patients, especially
with dissection to the distal end of the coronary artery.

KEYWORDS

Coronary Balloon Angioplasty, Percutaneous Coronary Intervention,
Myocardial Infarction, Intravascular Ultrasonography, Computed
Tomography Angiography

1. INTRODUCTION

Spontaneous coronary artery dissection (SCAD) has emerged as an
important cause of acute coronary syndrome, particularly in young
woman.\textsuperscript{1-3} Although recent studies have demonstrated
that conservative therapy is appropriate for the initial management of
SCAD, revascularization should be considered in a patient with ongoing
ischemia, high-risk anatomy, or hemodynamic
instability.\textsuperscript{4,5} Percutaneous coronary intervention
(PCI) for SCAD treatment is associated with an increased risk of
complications and suboptimal outcomes; however, several case reports
have shown the efficacy of coronary artery fenestration with cutting
balloon angioplasty. \textsuperscript{6-8} Here, we present the case of
a patient with SCAD whose ischemia was not corrected with coronary
artery fenestration alone but was successful revascularized by the
additional use of the subintimal transcatheter withdrawal (STRAW)
technique.\textsuperscript{9,10}

2. CASE PRESENTATION

A 31-year-old woman with a history of smoking but no prior coronary
artery disease was admitted to our hospital at 20 weeks of gestation for
impending preterm labor. At 36 weeks of gestation, a cesarean section
was performed. However, 2 days thereafter, she developed chest pain with
anterior ST-segment elevation on electrocardiogram, indicative of acute
myocardial infarction. Emergency coronary angiography (CAG) showed
subtotal occlusion in the middle part of the left anterior descending
artery (LAD), and there appeared to be a contrast delay distally. In
order to confirm the cause of subtotal occlusion, an IVUS (Opti-Cross
HD, Boston Scientific, Inc., Marlborough, MA, USA) examination was
performed (Figure 1). IVUS demonstrated that the false lumen compressed
the true lumen from the middle to distal part of the LAD. Based on the
findings of the CAG and IVUS, she was diagnosed with type-1 SCAD. The
IVUS catheter was advanced as far distally as possible; however, the
distal end of the false lumen could not be identified. We decided to
perform primary PCI because of ongoing chest pain and persistent
ST-segment elevation. First, we attempted coronary artery fenestration
using cutting balloon angioplasty. A 3.5-mm cutting balloon (Wolverine,
Boston Scientific, Inc., Marlborough, MA, USA) was advanced into the
distal LAD where the IVUS catheter could be advanced and then dilated.
The IVUS findings after cutting balloon angioplasty showed the creation
of some reentries; however, the true lumen at the distal LAD was still
compressed by the hematoma in the false lumen. In order to make an
additional fenestration at a more distal site, we attempted to advance a
2.5-mm cutting balloon (Wolverine, Boston Scientific, Inc., Marlborough,
MA, USA); however, this attempt was unsuccessful. Therefore, we then
applied the STRAW technique. A second guidewire (SUOH03, ASAHI INTECC
CO., LTD, Aichi, Japan) was intentionally advanced into the false lumen
under real-time IVUS guidance, and a microcatheter (FINECROSS GT, TERUMO
Corp., Tokyo, Japan) was also advanced into the false lumen at the far
distal part of the LAD. After the guidewire was removed, we aspirated
blood from the tip of the microcatheter while gradually moving the
microcatheter position to the proximal side; then, ST-segment elevation
improved, and chest pain disappeared (Figure 2). We attempted to advance
a 2.5-mm cutting balloon again, and it was able to advance more distally
than before the STRAW technique; thereafter, coronary artery
fenestration was performed at the distal LAD. The IVUS findings after
the STRAW technique and the additional coronary artery fenestration at
the distal LAD showed an enlarged true lumen and multiple reentries
formations. Although there were several stenoses in the middle part of
the LAD due to compression by the false lumen, coronary artery blood
flow improved to Thrombolysis in Myocardial Infarction (TIMI) flow grade
2 (Figure 3,4). Considering the absence of ongoing ischemia and the
patient's age and gender, we decided to complete the procedure without
stenting. The post-procedural course was good and uneventful till 10
months thereafter. We followed up the patient with coronary computed
tomographic angiography; the flap and the stenosis at the middle part of
the LAD disappeared after 10 months of PCI (Figure 5).

3. DISCUSSION

Previous observational studies have consistently shown that PCI for SCAD
treatment is associated with an increased risk of complications and
suboptimal outcomes. \textsuperscript{1-5} However, owing to ongoing
ST-segment elevation, we performed primary PCI for this patient.

Some case reports have shown the efficacy of coronary artery
fenestration with cutting balloon angioplasty to decompress the hematoma
and avoiding longitudinal extension. \textsuperscript{6-8} We also
attempted this technique; however, our attempt was unsuccessful. We
believe the following reasons were responsible for the failure of this
attempt: 1) the cutting balloon could not advance sufficiently distally
because the true lumen was severely compressed by the false lumen and 2)
the dissection had reached the distal end of the LAD; therefore,
coronary artery fenestration could not be made at the distal end of the
false lumen, and the compression of the true lumen was not released by
the remaining hematoma in the false lumen. In order to overcome these
problems, we used the STRAW technique. \textsuperscript{9,10}

The STRAW technique was reported as an option to decompress the distal
true lumen and enable successful reentry for antegrade in chronic total
occlusion cases. In the original method, an over-the-wire balloon was
positioned in the proximal vessel at the site of origin of the
dissection plane. Following balloon inflation, a 10-mL syringe was
attached to the proximal lumen port on the negative
pressure.\textsuperscript{10} In addition, the case report of iatrogenic
coronary artery dissection from our hospital has shown that aspiration
using a microcatheter could reduce the hematoma in the false
lumen.\textsuperscript{11} In this case, we performed microcatheter
aspiration to successfully improve the ongoing ischemia. Furthermore, it
became possible to deliver a cutting balloon to a more distal part of
the LAD, and we succeeded in performing the coronary artery fenestration
at a sufficiently distal side. We believe that aspiration using a
microcatheter offers the advantage of safe advancement of the aspiration
device to the distal part of the false lumen. However, if microcatheter
aspiration is insufficient, it may be helpful to perform aspiration
during balloon occlusion in the proximal vessel, referring to the
original method.

PCI in SCAD should focus on restoring the TIMI flow grade and
stabilizing the patient clinically rather than restoring normal coronary
artery structure. \textsuperscript{2} Moreover, systematic studies have
been reported on whether stents should be used in PCI for SCAD. In this
case, we decided to perform stent-less PCI because ST-segment elevation
and TIMI flow grade improved, and the patient was a young woman.
Observational data have shown that spontaneous healing occurs in most
SCAD patients \textsuperscript{3}, and in the present case, coronary
computed tomographic angiography still showed healing of the SCAD
lesion.

This new PCI strategy that combined the STRAW technique and coronary
artery fenestration using a cutting balloon appeared effective in SCAD
patients; however, a more large-scale study is required to confirm the
safety and efficacy of this method.

4. CONCLUSION

A combination of the STRAW technique and coronary artery fenestration
with cutting balloon angioplasty could be effective in SCAD patients,
with dissection to the distal end of the coronary artery. However, a
more large-scale evaluation is required to confirm the safety and
efficacy of this method.

CONFLICT OF INTEREST

The authors declare that there is no conflict of interest.

AUTHOR CONTRIBUTIONS

SM: involved in management of the patient and wrote the article. KO, MM,
and KU: involved in critically reviewed and revision of the manuscript.
All authors: approved the final version of the case report for
submission to \emph{Clinical Case Reports} .

ETHICAL STATEMENT

Published with written consent of the patient.

REFERENCES

1. Kim ESH. 2020. Spontaneous Coronary-Artery Dissection. \emph{N Engl J
Med} . 383(24):2358-2370.

2. Hayes SN, Tweet MS, Adlam D, et al. 2020. Spontaneous Coronary Artery
Dissection: JACC State-of-the-Art Review. \emph{J Am Coll Cardiol} .
76(8):961-984.

3. Hayes SN, Kim ESH, Saw J, et al. 2018. Spontaneous Coronary Artery
Dissection: Current State of the Science: A Scientific Statement From
the American Heart Association. \emph{Circulation} . 137(19):e523-e557.

4. Lettieri C, Zavalloni D, Rossini R, et al. 2015. Management and
Long-Term Prognosis of Spontaneous Coronary Artery Dissection. \emph{Am
J Cardiol} . 116(1):66-73.

5. Tweet MS, Eleid MF, Best PJ, et al. 2014. Spontaneous coronary artery
dissection: revascularization versus conservative therapy. \emph{Circ
Cardiovasc Interv} . 7(6):777-786.

6. Bresson D, Calcaianu M, Lawson B, Jacquemin L. 2019. Coronary artery
fenestration as rescue management of intramural haematoma with luminal
compression. \emph{Catheter Cardiovasc Interv} . 94(1):E17-E19.

7. Ito T, Shintani Y, Ichihashi T, Fujita H, Ohte N. 2017.
Non-atherosclerotic spontaneous coronary artery dissection
revascularized by intravascular ultrasonography-guided fenestration with
cutting balloon angioplasty. \emph{Cardiovasc Interv Ther} .
32(3):241-243.

8. Motreff P, Barber-Chamoux N, Combaret N, Souteyrand G. 2015. Coronary
artery fenestration guided by optical coherence tomograhy before
stenting: new interventional option in rescue management of compressive
spontaneous intramural hematoma. \emph{Circ Cardiovasc Interv} .
8(4):e002266.

9. Wu EB, Brilakis ES, Lo S, et al. 2020. Advances in CrossBoss/Stingray
use in antegrade dissection reentry from the Asia Pacific Chronic Total
Occlusion Club. \emph{Catheter Cardiovasc Interv} . 96(7):1423-1433.

10. Smith EJ, Di Mario C, Spratt JC, et al. 2015. Subintimal
TRAnscatheter Withdrawal (STRAW) of hematomas compressing the distal
true lumen: a novel technique to facilitate distal reentry during
recanalization of chronic total occlusion (CTO). \emph{J Invasive
Cardiol} . 27(1):E1-4.

11. Nagata Y, Maruyama M, Aburadani I, Hirazawa M, Mayumi T, Usuda K.
2015. A case of delayed occlusive dissection of the right coronary
artery during coronary intervention of the left anterior descending
artery. \emph{Cardiovasc Interv Ther} . 30(2):155-161.

FIGURE LEGENDS

FIGURE 1 Baseline left coronary angiography and IVUS images. The
angiography (left) shows subtotal occlusion in the middle part of the
LAD, and there appeared to be a contrast delay distally. IVUS images
from middle to distal LAD (right) demonstrate the false lumen
compressing the true lumen. t = true lumen, f = false lumen.

FIGURE 2 The STRAW technique using a microcatheter. The first guidewire
(arrowhead) was placed into the true lumen, and the microcatheter
(arrow) advanced into the false lumen at the far distal part of the LAD.
With the application of negative pressure using a syringe, the hematoma
was aspirated from the tip of the microcatheter, while gradually moving
the microcatheter position to the proximal part.

FIGURE 3 Final coronary angiography and IVUS images. The angiography
(left) shows improvement in the coronary artery blood flow from TIMI 1
to 2. In addition, small side branches at distal LAD can be observed.
IVUS images (right) demonstrate multiple connections between the true
lumen and the false lumen, with true lumen enlargement (D-F). t = true
lumen, f = false lumen.

FIGURE 4 Comparison of the IVUS images during each procedure (baseline,
pre-STRAW, final). IVUS images recorded at approximately the same site
are placed side by side. t = true lumen, f = false lumen.

FIGURE 5 Coronary computed tomographic angiography images for follow up
after PCI. Each image shows multiplanar reconstructed images of LAD, (A)
1 week, (B) 2 weeks, (C) 2 months, (D) 10 months after PCI. The flap and
coronary artery stenosis in the middle of the LAD (arrow) gradually
disappeared.\selectlanguage{english}
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