International Journal of Cardiology 201 (2015) 163–164
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
The reverse accordion effect Alexander Goldberg a,b,⁎, Irena Nordkin c, Majdi Halabi b,c, Inna Rosenfeld c a b c
Interventional Cardiology, Ziv Medical Center, Zfat, Israel Faculty of Medicine in Galilee, Bar-Ilan University, Zfat, Israel Cardiology Department, Ziv Medical Center, Zfat, Israel
a r t i c l e
i n f o
Article history: Received 27 July 2015 Accepted 1 August 2015 Available online 2 August 2015 Keywords: Coronary angioplasty Complications Accordion effect
The term “accordion effect” or “accordion phenomenon” is used to describe the appearance of new pseudo lesions after advancement of coronary wire or other devices through tortuous segments of a coronary or peripheral artery [1–5]. This causes mechanical straightening and shortening of an artery by stiff intravascular equipment with intraluminal invaginations of vessel wall, sometimes leading to reduced coronary flow and ischemia. Recognising accordion effect in this clinical setting is important in order to select a correct treatment strategy. In previously published cases the accordion effect occurred during coronary angioplasty while advancing a coronary wire or other equipment through a tortuous artery. Here we describe the clinically significant accordion effect that was caused by withdrawal of the balloon after stent deployment and affected a segment proximal to percutaneous coronary intervention (PCI) site. A 73-year-old woman underwent cardiac catheterization because of angina pectoris and myocardial perfusion scan suggestive of anterior wall ischemia. On coronary angiography she had tortuous and calcified coronaries with significant stenosis in the distal part of the left anterior descending artery (LAD) (Fig. 1). A soft hydrophilic guidewire (Whisper MS, Abbot Vascular, Santa Clara, CA) was advanced through the lesion to distal LAD and predilatation with a semi-compliant balloon (Mini-Trek, Abbot Vascular, Santa Clara, CA) was performed. With some difficulties, a drug-eluting stent (Yukon PC, Translumina GmbH, Hechingen, Germany) was delivered and deployed at the stenosis site (Fig. 2). Immediately after the balloon retrieval the patient complained of severe
⁎ Corresponding author at: Interventional Cardiology, Ziv MC, Zfat, Israel. E-mail address: [email protected] (A. Goldberg).
http://dx.doi.org/10.1016/j.ijcard.2015.08.040 0167-5273/© 2015 Elsevier Ireland Ltd. All rights reserved.
chest pain and ST segment elevation was seen at the monitor. On coronarography the previously tortuous middle LAD was straitened and multiple tight stenoses were observed proximally to the deployed stent with the coronary flow impairment to distal LAD (Fig. 3). The administration of intracoronary nitroglycerine had no effect. Under assumption that the new lesions were created by straitening of the tortuous middle LAD by pulling out the balloon on the wire, the wire was removed with immediate resolution of the symptoms. The coronarography confirmed the restoring of the original LAD curvature and complete restoration of flow (Fig. 4). The patient was discharged home the next day and remains asymptomatic at six-months follow up. The accordion effect usually occurs when advancing a wire through a tortuous artery causes kinking and invaginations of vessel wall creating multiple pseudo lesions [1–3]. This may cause an impairment of coronary flow and ischemia [4,6]. In these cases intracoronary vasodilators are usually not effective and complete or partial removal of the wire is required to restore the original configuration of the coronary artery. In our case, the wire, balloon and stent were uneventfully passed through the tortuous artery, but the retrieval of the balloon after stent deployment straitened the artery and caused accordion effect and ischemia. We speculate that calcification of the artery and numerous side branches prevented the change of vessel geometry during introducing
Fig. 1. A right anterior oblique (RAO) cranial view of the LAD showing the tortuous middle segment and the significant stenosis in its distal segment (arrow).
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A. Goldberg et al. / International Journal of Cardiology 201 (2015) 163–164
Fig. 2. The stent deployment (black arrow). Note the preserved curvature of the middle segment (hollow arrow).
Fig. 4. The complete restoration of the middle LAD curvature and disappearance of the pseudo lesions after wire removal (hollow arrow) with good flow to the distal LAD with patent stent (black arrow).
deployment can be challenging and includes dissection, spasm, distal embolization and thrombus formation. The recognition of accordion effect as a possible reason of coronary flow impairment and ischemia after stent deployment is important in order to select an appropriate strategy and to avoid unnecessary interventions. Conflict of interest The authors report no relationships that could be construed as a conflict of interest. References
Fig. 3. The reverse accordion effect. The straitened middle LAD after the balloon retrieval with multiple stenoses (hollow arrows) with the coronary wire in the distal segment (black arrow).
coronary equipment to the stenosis site, but pulling out the balloon after stent deployment applied the additional longitudinal force straightening the artery and causing the accordion effect. To the best of our knowledge, this is a first report of accordion effect caused by withdrawal of coronary equipment from the artery, rather than by advancing it into the artery. The differential diagnosis of acute ischemia after stent
[1] O. Muller, M. Hamilos, A. Ntalianis, G. Sarno, B. De Bruyne, Images in cardiovascular medicine. The accordion phenomenon: lesson from a movie, Circulation 118 (2008) e677–e678. [2] S. Ishikawa, K. Asakura, T. Okabe, H. Kanki, S. Ito, M. Shibata, et al., Successful stenting on tortuous coronary artery with accordion phenomenon: strategy: a case report, Angiology 50 (1999) 765–770. [3] G. Davidavicius, G. Manoharan, B. De Bruyne, The accordion phenomenon, Heart 91 (2005) 471. [4] Y. Yasuoka, D. Morisawa, H. Kitada, S. Hattori, Y. Noda, H. Adachi, et al., An accordion phenomenon with ST-segment elevation of electrocardiogram and anginal chest pain: a case report, Int. J. Cardiol. 135 (2009) e62–e64. [5] E. Puymirat, M. Vanderheyden, B. De Bruyne, Accordion phenomenon induced by pressure wire, Int. J. Cardiol. 148 (2011) 375–376. [6] N. Oyama, K. Urasawa, H. Sakai, A. Kitabatake, A case of accordion phenomenon accompanied by severe transmural myocardial ischemia, Jpn. Heart J. 43 (2002) 49–54.
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
The reverse accordion effect Alexander Goldberg a,b,⁎, Irena Nordkin c, Majdi Halabi b,c, Inna Rosenfeld c a b c
Interventional Cardiology, Ziv Medical Center, Zfat, Israel Faculty of Medicine in Galilee, Bar-Ilan University, Zfat, Israel Cardiology Department, Ziv Medical Center, Zfat, Israel
a r t i c l e
i n f o
Article history: Received 27 July 2015 Accepted 1 August 2015 Available online 2 August 2015 Keywords: Coronary angioplasty Complications Accordion effect
The term “accordion effect” or “accordion phenomenon” is used to describe the appearance of new pseudo lesions after advancement of coronary wire or other devices through tortuous segments of a coronary or peripheral artery [1–5]. This causes mechanical straightening and shortening of an artery by stiff intravascular equipment with intraluminal invaginations of vessel wall, sometimes leading to reduced coronary flow and ischemia. Recognising accordion effect in this clinical setting is important in order to select a correct treatment strategy. In previously published cases the accordion effect occurred during coronary angioplasty while advancing a coronary wire or other equipment through a tortuous artery. Here we describe the clinically significant accordion effect that was caused by withdrawal of the balloon after stent deployment and affected a segment proximal to percutaneous coronary intervention (PCI) site. A 73-year-old woman underwent cardiac catheterization because of angina pectoris and myocardial perfusion scan suggestive of anterior wall ischemia. On coronary angiography she had tortuous and calcified coronaries with significant stenosis in the distal part of the left anterior descending artery (LAD) (Fig. 1). A soft hydrophilic guidewire (Whisper MS, Abbot Vascular, Santa Clara, CA) was advanced through the lesion to distal LAD and predilatation with a semi-compliant balloon (Mini-Trek, Abbot Vascular, Santa Clara, CA) was performed. With some difficulties, a drug-eluting stent (Yukon PC, Translumina GmbH, Hechingen, Germany) was delivered and deployed at the stenosis site (Fig. 2). Immediately after the balloon retrieval the patient complained of severe
⁎ Corresponding author at: Interventional Cardiology, Ziv MC, Zfat, Israel. E-mail address: [email protected] (A. Goldberg).
http://dx.doi.org/10.1016/j.ijcard.2015.08.040 0167-5273/© 2015 Elsevier Ireland Ltd. All rights reserved.
chest pain and ST segment elevation was seen at the monitor. On coronarography the previously tortuous middle LAD was straitened and multiple tight stenoses were observed proximally to the deployed stent with the coronary flow impairment to distal LAD (Fig. 3). The administration of intracoronary nitroglycerine had no effect. Under assumption that the new lesions were created by straitening of the tortuous middle LAD by pulling out the balloon on the wire, the wire was removed with immediate resolution of the symptoms. The coronarography confirmed the restoring of the original LAD curvature and complete restoration of flow (Fig. 4). The patient was discharged home the next day and remains asymptomatic at six-months follow up. The accordion effect usually occurs when advancing a wire through a tortuous artery causes kinking and invaginations of vessel wall creating multiple pseudo lesions [1–3]. This may cause an impairment of coronary flow and ischemia [4,6]. In these cases intracoronary vasodilators are usually not effective and complete or partial removal of the wire is required to restore the original configuration of the coronary artery. In our case, the wire, balloon and stent were uneventfully passed through the tortuous artery, but the retrieval of the balloon after stent deployment straitened the artery and caused accordion effect and ischemia. We speculate that calcification of the artery and numerous side branches prevented the change of vessel geometry during introducing
Fig. 1. A right anterior oblique (RAO) cranial view of the LAD showing the tortuous middle segment and the significant stenosis in its distal segment (arrow).
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A. Goldberg et al. / International Journal of Cardiology 201 (2015) 163–164
Fig. 2. The stent deployment (black arrow). Note the preserved curvature of the middle segment (hollow arrow).
Fig. 4. The complete restoration of the middle LAD curvature and disappearance of the pseudo lesions after wire removal (hollow arrow) with good flow to the distal LAD with patent stent (black arrow).
deployment can be challenging and includes dissection, spasm, distal embolization and thrombus formation. The recognition of accordion effect as a possible reason of coronary flow impairment and ischemia after stent deployment is important in order to select an appropriate strategy and to avoid unnecessary interventions. Conflict of interest The authors report no relationships that could be construed as a conflict of interest. References
Fig. 3. The reverse accordion effect. The straitened middle LAD after the balloon retrieval with multiple stenoses (hollow arrows) with the coronary wire in the distal segment (black arrow).
coronary equipment to the stenosis site, but pulling out the balloon after stent deployment applied the additional longitudinal force straightening the artery and causing the accordion effect. To the best of our knowledge, this is a first report of accordion effect caused by withdrawal of coronary equipment from the artery, rather than by advancing it into the artery. The differential diagnosis of acute ischemia after stent
[1] O. Muller, M. Hamilos, A. Ntalianis, G. Sarno, B. De Bruyne, Images in cardiovascular medicine. The accordion phenomenon: lesson from a movie, Circulation 118 (2008) e677–e678. [2] S. Ishikawa, K. Asakura, T. Okabe, H. Kanki, S. Ito, M. Shibata, et al., Successful stenting on tortuous coronary artery with accordion phenomenon: strategy: a case report, Angiology 50 (1999) 765–770. [3] G. Davidavicius, G. Manoharan, B. De Bruyne, The accordion phenomenon, Heart 91 (2005) 471. [4] Y. Yasuoka, D. Morisawa, H. Kitada, S. Hattori, Y. Noda, H. Adachi, et al., An accordion phenomenon with ST-segment elevation of electrocardiogram and anginal chest pain: a case report, Int. J. Cardiol. 135 (2009) e62–e64. [5] E. Puymirat, M. Vanderheyden, B. De Bruyne, Accordion phenomenon induced by pressure wire, Int. J. Cardiol. 148 (2011) 375–376. [6] N. Oyama, K. Urasawa, H. Sakai, A. Kitabatake, A case of accordion phenomenon accompanied by severe transmural myocardial ischemia, Jpn. Heart J. 43 (2002) 49–54.
