The other day a patient developed acute left main occlusion within 20 minutes of a what looked like a successful PCI. When the angiogram was analysed there was a distinct possibility of left main dissection.
The common causes for left main injury during PCI include
- The guide catheter can it self injure the tender left main ostium by size mis-match
- The frequent adjustment of guiding catheter to get a co -axial alignment caries a definite risk
- The guide catheter slipping and subsequent repositioning with the guide wire precariously snaring the left main ostia is the single important cause for left main injury.
How to prevent left main injury ?
- Optimal guide catheter size and shape is vital.
- Smaller the size it is better .(6 F is ideal for most )
- As for as possible minimal handling of guide catheter is adviced . (Hands always on guiding catheter approach is to be discouraged )
- Deeper engagement of guide catheter as far as possible without hemo-dynamic compromise.This will ensure not only better support for guide wire and balloon , low chances for guide wire to injure the left main ostia
- Tapering guiding catheters with soft ends are ideal. ( Which are available I think !)
- Finally and most importantly keep the PCI procedure as short as possible , come out quickly . After all , we play the dangerous coronary game right in the mouth of the mysterious coronary cave ( of Alibaba ! ) called Left main !