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The angiographic appearances of complications during coronary angioplasty such as coronary artery dissection, spasm or thrombus formation are well recognised. These situations require specific corrective measures such as stenting, intracoronary nitrates or infusion of glycoprotein IIb/IIIa inhibitors. However, not all coronary artery abnormalities seen during coronary angioplasty are true lesions that require treatment. We report a case of lesions appearing in the proximal vessel during right coronary angioplasty that were artefactual.
Panel A below shows the diagnostic angiogram with the original stenosis in distal right coronary artery arrowed. In panel B, this stenosis has been successfully stented, but apparent severe stenoses (bold arrow) have appeared at the site of vessel tortuosity in the proximal segment of the “shepherd's crook” right coronary artery, with the guidewire in situ. In panel C, the guidewire has been withdrawn allowing the right coronary artery to assume its natural curvature and the lesions have disappeared.
The apparent lesions were the result of the guidewire straightening out tortuous segments of the artery and causing vessel wall invagination, also described as the “accordion effect”. These angiographic appearances must be recognised to avoid unnecessary stenting of arterial segments that are not diseased. The guidewire should be withdrawn until the floppy tip lies within the suspected segment to enable the vessel to resume its original shape, so that the diagnosis of an artefactual lesion can be confirmed without losing guidewire position (panel C). The right coronary artery is thought to be particularly susceptible to this phenomenon because the artery lies relatively unsupported by surrounding tissue in the atrioventricular groove.