Akut Koroner Sendrom İşleminde Gelişen Koroner Diseksiyonun IVUS Eşliğinde Kurtarılması
Özet
Koroner anjiyografi ve perkütan koroner girişimler, akut koroner sendrom (AKS) tedavisinde yaygın olarak kullanılan invaziv yöntemlerdir. Bununla birlikte, işlem sırasında nadir görülmesine rağmen ciddi klinik sonuçlara yol açabilen iyatrojenik koroner arter diseksiyonu (İKAD) gelişebilir. Diseksiyonun ilerlemesi, gerçek lümenin kaybına ve koroner kan akımının bozulmasına neden olarak hemodinamik instabilite ve miyokard hasarı ile sonuçlanabilir. İntravasküler ultrason (IVUS), gerçek ve yalancı lümenin ayrımını sağlayarak kılavuz telin doğru konumlandırılmasına ve uygun tedavi stratejisinin belirlenmesine yardımcı olan önemli bir görüntüleme yöntemidir. Bu olgu da hastamız AKS tanısı ile acil koroner anjiyografiye alındı. Koroner anjiyografide sağ koroner arter (RCA) proksimal segmentinde tam oklüzyon saptanması üzerine perkütan koroner girişim uygulandı. Trombüs aspirasyonu sonrası akım sağlanmasına rağmen stentleme işlemi sırasında kılavuz tel manipülasyonuna bağlı National Heart, Lung, and Blood Institute (NHLBI) sınıflamasına göre Tip F koroner diseksiyon gelişti ve damar tekrar oklüde oldu. Kılavuz telin yalancı lümende olduğu görüldü. Diseksiyonun genişlemesini önlemek ve anatomiyi değerlendirmek amacıyla IVUS uygulandı. IVUS rehberliğinde gerçek lümen tespit edilerek ikinci kılavuz tel doğru pozisyona yerleştirildi. Ardından diseksiyon segmentini kapsayacak şekilde ilaç salınımlı stentler implante edildi ve IVUS ile stent ekspansiyonu doğrulandı. İKAD, perkütan koroner girişimlerin nadir ancak hayatı tehdit edebilen komplikasyonlarından biridir. Bu olgu, IVUS kullanımının gerçek lümenin belirlenmesi, kılavuz tel yönlendirilmesi ve başarılı stentleme stratejisinin oluşturulmasındaki kritik rolünü göstermektedir. IVUS rehberli yaklaşım, uygun hasta seçimi ve deneyimli operatör yönetimi ile kompleks koroner diseksiyonların güvenli ve etkili şekilde tedavi edilmesini sağlayabilir.
Coronary angiography and percutaneous coronary interventions (PCI) are widely used invasive treatment methods in the management of acute coronary syndrome (ACS). However, iatrogenic coronary artery dissection (ICAD), although rare, may develop during these procedures and can lead to serious clinical consequences. Progression of dissection may result in loss of the true lumen, impaired coronary blood flow, hemodynamic instability, and myocardial injury. Intravascular ultrasound (IVUS) is an important imaging modality that enables differentiation between the true and false lumens, facilitates proper guidewire positioning, and assists in determining the appropriate treatment strategy. In this case, a patient diagnosed with ACS was urgently referred for coronary angiography. A total occlusion was detected in the proximal segment of the right coronary artery (RCA), and percutaneous coronary intervention was performed. Although coronary flow was restored after thrombus aspiration, a type F coronary artery dissection according to the National Heart, Lung, and Blood Institute (NHLBI) classification developed due to guidewire manipulation during stent implantation, resulting in re-occlusion of the vessel. As the guidewire was found to be located in the false lumen, IVUS was performed to prevent progression of the dissection and to evaluate coronary anatomy. Under IVUS guidance, the true lumen was identified, and a second guidewire was successfully positioned within the true lumen. Subsequently, drug-eluting stents were implanted covering the dissected segment, and optimal stent expansion was confirmed by IVUS. Iatrogenic coronary artery dissection is a rare but potentially life-threatening complication of percutaneous coronary intervention. This case highlights the critical role of IVUS in identifying the true lumen, guiding wire positioning, and establishing an effective revascularization strategy. An IVUS-guided approach, combined with appropriate patient management and experienced operators, may enable safe and successful treatment of complex coronary dissections.
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