Pleating Artifact: A Mimicker of Spasm, Clot and Dissection

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. 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. 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 The stent was withdrawn to the catheter, with some relief in the spasm, but the filling defects still existed and the vessel did not regain its serpentine curves. The wire was partially withdrawn. The spasm relieved with no filling defect and the vessel returned to its previous serpentine shape. The stent was positioned with much difficulty, because the straightened, pleated artery could not be matched to the serpentine artery in the reference image. Post stent deployment, the wire was withdrawn partially. The spasm and filling defects vanished, with the restoration of the baseline curvatures in the RCA. Final appearance after the complete withdrawal of the PT Graphix wire showed normal curvatures of the RCA and no artifact.

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