Summary:We report three patients who developed iatrogenic severe left main coronary artery stenosis. In two, it was secondary to coronary cannulation during aortic valve replacement and in one it followed distention of the artery during balloon dilatation of a proximal lesion in the left anterior descending artery. In all three, the stenosis was clinically manifest a few months after the intervention. All were successfully treated by aortosaphenous coronary bypass. A common mechanism for the three cases may be mechanical distention of the left main coronary artery resulting in intimal damage with secondary fibrosis and stenosis. The percutaneous transluminal coronary angioplasty-related stenosis is, to our knowledge, the first reported case of this nature, and represents a previously unrecognized complication of this procedure.
Carotid artery dissection is a rare cause of cerebral vascular insufficiency. It is usually due to extension of the dissection in the aortic arch' and less commonly to isolated spontaneous dissection in the carotid Although noninvasive evaluation using pulsed Doppler techniques or oculoplethysmography may reveal secondary flow disturbance^,^,^ contrast angiography is still the standard test to confirm the diagnosis and outline the anatomy. We present a case of carotid dissection diagnosed by real-time ultrasonography in a patient who had a previous aortic arch dissection. CASE REPORTA 68-year-old woman was seen because of episodes of blurred vision in the right eye and transient weakness in the right leg. Nine months earlier, the patient underwent repair of a DeBakey type I aortic arch dissection. At that time aortic angiograms revealed a circumferential aortic dissection starting 2 cm above the aortic annulus. Operative repair was performed using a dacron graft. The postoperative course was uneventful. On physical examination, the patient was alert. Her blood pressure was 100/60 in the right arm and 160/60 in the left arm. Pulse rate was 70 beatdminute and regular. Carotid pulses were brisk and symmetrical. Palpable thrills and audible bruits were present in both sides. The apical impulse was hyperactive and displaced laterally. Auscultation revealed a fourth heart sound, a grade 3/6 ejection precordial murmur, and a grade 2/6 diastolic parasternal murmur. Neuro- (Fig. l), an image quite typical of arterial dissection. The abnormality involved the common bulb and the internal carotid artery as well. Ultrasonography of the left carotid artery revealed a severe stenotic lesion in the left internal carotid artery. Aortic arch angiography disclosed the postoperative changes in the aortic arch and dissection of the right common carotid artery extending into and terminating at the internal carotid artery (Fig. 2). Stenosis of the left carotid artery was also apparent. Since symptoms were attributable to the left carotid obstruction, endarterectomy of this artery was performed while dissection of the right carotid artery was treated conservatively with propranolol20 mg every 6 hours. The patient did well after the operation without recurrence of neurological symptoms. DISCUSSION
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