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Prominent role of tensile stress in propagation of a dissection after coronary stenting: computational fluid dynamic analysis on true 3d-reconstructed segment.

A 61-year-old man underwent direct stenting in the mid right coronary artery with a 3.5×18-mm stent deployed at a pressure of 14 atm. Without further balloon inflation, the control angiogram showed a stepdown-like pattern at the distal edge of the stent (Figure 1A). At that site, intravascular ultrasound (IVUS) imaging (see Movie, available at http://www.circulationaha.org) showed a ruptured plaque and a minor dissection. Shortly after IVUS, the dissection extended distally and became subocclusive (Figure 1, B and C). Deployment of 2 additional stents arrested propagation of the dissection. The final angiogram showed a satisfactory result, with TIMI 3 flow. Despite the importance of edge dissection, the mechanism of propagation in coronary arteries has not been described. It seems reasonable that the pressure force induced by flow on a dissected flap would stimulate propagation. To study this flow-induced force, the coronary artery lumen and wall were reconstructed in true 3D (Figure 2A) by fusion of angiographic and IVUS data. Application of computational fluid dynamics to the reconstruction visualized the pressure development in the axial direction …