Dr. Irfan Muhammad can be contacted at firstname.lastname@example.org. Dr. Malik Faisal Iftekhar can be contacted at email@example.com.
A 72-year-old man presented with angina functional class II with ongoing guideline-directed medical therapy. There were dynamic ST and T changes in the inferior leads. Coronary angiography showed a serpentine right coronary artery (RCA) with a discrete 70% stenosis in the mid portion of the vessel (Figures 1-2).
The patient was planned for angioplasty of the mid RCA. A Judkins right guiding catheter was used to engage the RCA. A PT Graphix wire (Boston Scientific) was selected to cross the lesion. While advancing the stent (an Integrity 2.75mm x 18mm stent, Medtronic), a test injection showed spasm and a filling defect in the proximal RCA. Moreover, the tortuosity was straightened upon crossing with the wire and stent (Figure 3). The patient was asymptomatic, with no ECG or hemodynamic warnings. Nitroglycerin was of no help to relieve the “spasm”. The stent was withdrawn to the catheter, with some relief in the spasm, but the filling defects still existed and the vessel did not regain its serpentine curves (Figure 4). The wire was partially withdrawn. The spasm relieved with no filling defect and the vessel returned to its previous serpentine shape (Figure 5). The stent was positioned with much difficulty, because the straightened, pleated artery could not be matched to the serpentine artery in the reference image. The severity of the lesion can be judged from the “waist” in the stent during deployment (Figure 6). The stent was fully deployed at 10 atm with no waist (Figure 7). Post stent deployment, the wire was withdrawn partially. The spasm and filling defects vanished, with the restoration of the baseline curvatures in the RCA (Figure 8). Final appearance after the complete withdrawal of the PT Graphix wire showed normal curvatures of the RCA and no artifact (Figure 9).
In a tortuous artery, the guide wire at times does not conform to the curves in the artery. Instead, the artery conforms to the straighter guide wire by getting enfolded (pleated). The folds in the lumen cause narrowing of the lumen with filling defects mimicking spasm and clots, respectively. At times, the dye stains between the folds, giving the appearance of dissection. Nitroglycerin is ineffective to relieve the spasm. Patients usually tolerate these changes well. These artifacts usually occur at arterial segments away from the segment being treated. All changes disappear on partial or complete withdrawal of the guide wire, and curvatures in the artery are restored. Positioning the stent in this case was quite difficult, because the lesion in the straightened artery could not be matched with the reference serpentine artery. Intravascular ultrasound (IVUS) or better, optical computed tomography (OCT), would have been far more helpful in positioning the stent (had these technologies been available). The wire was withdrawn and the artery regained its curvatures. The stent was positioned with reference to the proximal radio-opaque part of the PT Graphix wire. Pleating is in no way similar to volvulus, as volvulus would mean twisting of the artery around a pedicle and wiring, if at all, will untwist, rather than causing volvulus. Moreover, volvulus will be catastrophic due to acute total occlusion. In telescoping, intusseption, or invagination, the proximal part of the artery would go with the wire into the distal part. This was not the case here, because when the wire was crossed across the tortuosities into the distal RCA, the artery retained its serpentine curves. When the wire was advanced into posterior descending artery, the artery was straightened and pleated in a jerk-like fashion (we wish we could record that beautiful phenomenon). We could find only one case report where pleating occurred in the left main coronary artery and circumflex artery during PCI on the circumflex.1
- Degirmencioglu A, Zencirci E, Karakus G. “Pleating artifact” in circumflex and left main coronary arteries resembling dissection during PCI. Cath Lab Digest. 2013 Oct; 21(10). Available online at http://www.cathlabdigest.com/articles/%E2%80%9CPleating-Artifact%E2%80%9D-Circumflex-Left-Main-Coronary-Arteries-Resembling-Dissection-During-PCI. Accessed September 23, 2015.