Aortic Dissection Caused by Percutaneous Coronary Intervention: 2 New Case Reports and Detailed Analysis of 86 Previous Cases

Abstract

A ortic dissection is a rare and potentially fatal sequela of percutaneous coronary intervention (PCI). The exact prevalence of aortic dissection after PCI is unknown, because occurrences might be unreported. The first case was reported in 1992. 1 We found 86 published instances 1-62 and have categorized these in detail. In addition, we present 2 new cases of aortic dissection consequent to PCI, and we discuss their specific treatment. Case Reports Patient 1A 52-year-old hypertensive man presented with acute inferior ST-segment-elevation MI (STEMI). He had a distant history of inferior myocardial infarction (MI) that had been treated with placement of a drug-eluting stent. At the current presentation, he was immediately taken for cardiac catheterization. Initial views of the left coronary system with use of a 6F Judkins left (JL)4 diagnostic catheter revealed no significant lesions. Views of the right coronary artery (RCA), examined with use of a 6F Judkins right (JR)4 diagnostic catheter, showed occlusion of the original proximal RCA stent. The diagnostic catheter was immediately removed, and a 6F JR4 guide catheter was used without difficulty to engage the RCA. A 180-cm Asahi Prowater Flex guidewire (Abbott Vascular, part of Abbott Laboratories; Abbott Park, Ill) was inserted into the RCA but could not cross the culprit lesion. This wire was exchanged for a 190-cm Hi-Torque Whisper guidewire (Abbott Vascular), and the lesion was successfully crossed with support from a 1.5 × 15-mm Maverick Over-the-Wire Balloon Catheter (Boston Scientific Corporation; Natick, Mass). Two brief inflations were done at pressures of 12 atm within the stent for 10 s each. The wire was upgraded to a 300-cm Asahi Prowater Flex wire while the Maverick balloon was still inside the artery. The patient reported chest pain, and his systolic blood pressure (SBP) fell to 78 mmHg. The balloon was removed. An angiogram showed dissection of the proximal RCA, extending retrograde into the right aortic cusp and ascending aorta (Fig. 1). In addition, slow flow and evidence of thrombus were noted in the RCA. A Pronto V3 extraction catheter (UDG Healthcare plc; Dublin, Ireland) was immediately inserted, and manual-aspiration thrombectomy was performed. Then, a 3.5 × 28-mm Vision ® bare-metal stent (Abbott Vascular), deployed in the proximal RCA at a pressure of 12 atm, was extended into the ostium to seal the dissection flap (Fig. 2).

Large iatrogenic aortic dissection from percutaneous coronary intervention resolved in 4 days

“…2 However, another case review recommended conservative management even in class 3 IAD. 3 Our case supports the latter view, that all classes of IAD in hemodynamically stable patients may be managed conservatively. Of note, this recommendation contrasts with 2010 multisociety guidelines for managing spontaneous aortic dissection, which recommend expedient surgery if the ascending aorta is involved.…”

Localized Aortic Root Dissection Secondary to Contrast Agent Injection: Feasibility of Conservative Follow-up With Echocardiography

“…4 Conservative treatment of uncomplicated retrograde dissection with blood pressure control, analgesics, and close observation has been recommended, especially in high-risk patients or those with previous cardiac surgery. 2,5 Although a CT scan is the best modality for conservative follow-up, it brings additional contrast load and radiation exposure as well as an increase in costs. 7 Conservative follow-up with echocardiogaphy as an appropriate imaging technique is suggested in such cases.…”

“…The majority of cases are catheter-induced. Spontaneous ACD secondary to contrast agent injection is rarely reported 1,2 ; however, the real-world prevalance is expected to be higher because of unreported cases. Parallel to increments in complex percutaneous coronary interventions, especially retrograde chronic total occlusion procedures, the incidence of ACD is expected to become more common.…”

“…Catheter trauma and subintimal progression of guidewires are major causes of ACD occurrence; isolated dissection secondary to radiocontrast injection is an extremely rare clinical entity. 2,3 The right coronary artery (RCA) ostium is involved in the majority of cases, and dissections are usually limited to the aortic sinus in half of clinical presentations. There are different treatment strategies, including interventional approaches, surgery, and medical follow-up.…”

Early Spontaneous Resolution of an Iatrogenic Acute Type A Aortic Dissection

“…Secondly, it would be dangerous handling the RCA with the stent extending through the ostium. dissections [6,7]. Shah et al [6] described a series of 86 patients, of whom 65 patients (76%) underwent stenting and/or conservative therapy with 3 deaths (3%).…”