Dr.S.Venkatesan MD

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

1. The guide catheter can it self  injure the tender left main ostium  by  size mis-match
2. The frequent adjustment of  guiding catheter to get a co -axial alignment caries a definite risk
3. 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 !