77 Address for correspondence: Johan Bennett, MD, Department of Cardiovascular Medicine, University Hospitals Leuven, Herestraat 49, B-3000 Leuven, Belgium. E-mail: johan. bennett@uzleuven.be Received 16 October 2012; accepted for publication 30 October 2012. CASE HISTORY AND DISCUSSION A 42-year-old lady with unremarkable medical his- tory and no cardiac risk factors was admitted with chest pain and dynamic antero-lateral ST-segment changes on the electrocardiogram (ECG). The diagnosis of a non-ST-segment elevation myocardial infarction (NSTEMI) was made based on positive cardiac biomark- ers. Urgent coronary angiography (CAG) revealed a significant stenosis of the mid left anterior descending artery (LAD) involving the bifurcation with the 2 nd diagonal branch (D2) (figure 1, A and B). The left main stem (LMS) was small with no visible atheroma. The circumflex (Cx) and the right coronary artery (RCA) were angiographically normal. It is not clear if intra- coronary (IC) vasodilators were used during CAG. The patient was percutaneously treated with a drug-eluting stent (DES) (2.25 × 18 mm) in the mid-LAD followed by kissing balloon inflation in LAD and D2 (figure 1, C and D). Coronary spasm is not a benign entity Stefanus A. WIYONO 1 , MD; Johan BENNETT 1 , MD; Bert FERDINANDE 1 , MD; Kaatje GOETSCHALCKX 1,2 , MD; Walter DESMET 1 , MD PhD; Christophe DUBOIS 1 , MD, PhD 1 Cardiovascular Diseases, University Hospitals Leuven, & Department of Cardiovascular Sciences, KU Leuven, Belgium; 2Radiology, University Hospitals Leuven, & Department of Imaging and Pathology, KU Leuven, Belgium. Case summary We present a case of unrecognized recurrent severe coronary spasm treated by percutaneous coronary interventions leading to catastrophic complications ultimately requiring emergency coronary artery bypass grafting and later, following occlusion of the grafts, recanalization of a totally occluded left coronary artery. Throughout the case history the recognition and management of this challenging coronary phenomenon is discussed. Keywords Coronary spasm – percutaneous coronary intervention – acute coronary syndrome. The variable size of the LAD in different projections and the overall narrow aspect of the vessel suggest the presence of coronary artery vasospasm. Coronary vaso- spasm is an important cause of reversible myocardial ischaemia, and is more prevalent in middle-aged women 1,2 . Administration of intracoronary (IC) vaso- dilators should be encouraged during routine CAG to optimize imaging and clarify ambiguous lesions. Despite its hypotensive effect, injection of nitroglycerin may even be warranted to overcome spasm and allow resto- ration of blood pressure in some cases. In the present case IC nitrates seem not to have been administrated. Stent size may have been underestimated in the presence of spasm. Finally, the result after stenting confirms the dynamic aspect of spasm, with now luminal narrowing at the level of the proximal stent edge. Four days after the first intervention, the patient presented with recurrent chest pain and transient ante- rior ST-segment elevation. Emergency CAG showed diffuse narrowing of the LMS and proximal LAD with subtotal occlusion proximal to the patent LAD stent (figure 2A). These findings were interpreted as a coro- nary artery dissection, and a second DES (2.25 × 28 mm) was implanted proximally to the first one. After deploy- ment, a subtotal occlusion of the proximal LAD segment was seen (figure 2B), and an additional DES (2.5 × 38 mm) was deployed from the body of the LMS to the mid-LAD. Kissing balloon inflation was performed in the LMS bifurcation, resulting in a satisfactory angiographic result (figure 2C). Acta Cardiol 2013; 68(1): 77-81 doi: 10.2143/AC.68.1.2959635 [ Case report ]