Aortocoronary Dissection Resolved by Coronary Stenting Guided by Intracoronary Ultrasound

Abstract

ortocoronary dissection is a rare complication of percutaneous coronary intervention (PCI). The trigger for aortocoronary dissections is a coronary dissection, which extends progressively into the coronary sinus of Valsalva and the ascending aorta. [1][2][3][4] We report a case of iatrogenic coronary dissection extending into the ascending aorta that was successfully resolved by ICUSguided coronary stenting. Case ReportA 70-year-old male was admitted for unstable angina. He had a past history of cerebral infarction and pulmonary silicosis for which he needed home oxygen therapy. Coronary angiography (CAG) revealed 2 chronic total occlusions (CTO): a proximal site in the dominant right coronary artery (RCA), and a distal site in the circumflex artery. There were other significant stenoses without occlusions in the mid-portion of the left anterior descending artery (LAD) and the diagonal branches. The diseased LAD supplied good collateral flow to the occluded RCA. Thallium-201 myocardial scintigraphy showed ischemia in the anteroseptal and inferior walls. He agreed to undergo PCI, because he was a high-risk patient for coronary bypass surgery with his reduced pulmonary function capacity.PCI to the CTO of the RCA was planned. The Amplatzs L-1 7Fr catheter was engaged in the ostium of the RCA, but manipulation of the guide wire in the catheter was difficult and it was exchanged for a Judkins-right 4. A 0.014-inch guide wire was able to cross the occlusion, but it was difficult with a balloon catheter because the lesion was very hard. Using more back-up force, the tip of the guide catheter was advanced closer to the CTO while rotating it clockwise, and as the balloon catheter was advanced to the CTO, the guide catheter was rotated a little counter clock-wise. The balloon catheter was pushed strongly while keeping Circulation Journal Vol.68, April 2004 the tip of the guide catheter in the RCA, and it successfully passed the hard lesion. After dilating the CTO, contrast injections to the RCA revealed a large dissection from where the tip of the guide catheter contacted RCA to the right coronary cusp (RCC). Balloon angioplasty with a 3.0-mm balloon was performed for the CTO and the dissection, while the guiding catheter was dislodged from the ostium and contrast injections were gently done. The area in the RCC dyed by contrast medium widened (Fig 1B), and the patient suddenly complained of anterior chest pain and back pain without ST change on the electrocardiogram. ICUS was immediately performed to get more information than was shown by CAG. ICUS (Fig 2) showed an entry point of a large dissection in the proximal RCA, which Circ J 2004; 68: 389 -391 (Received March 20, 2002; revised manuscript received August 8, 2002; accepted August 29, 2002) The Department of Cardiology, Niigata City General Hospital, Niigata, Japan Mailing address: Hirotaka Oda, MD, The Department of Cardiology, Niigata City General Hospital, 2-6-1 Shichikuyama, Niigata 950-8739, Japan. E-mail: oda@hosp.niigata.niigata.jp

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

“…We found 86 cases of aortic dissection caused by percutaneous coronary angiography or PCI (Table I). Ten of those occurred during attempted intervention on chronic total occlusion (Table II), 36,[47][48][49][50][51][52][53][54][55] and 7 were in patients who had histories of CABG (Table III). [56][57][58][59][60][61][62] Of the 86 cases, 26 (30.2%) occurred during emergency catheterization.…”

Iatrogenic Aortic Dissection Complicating Percutaneous Coronary Intervention for Chronic Total Occlusion

“…Indeed, guiding catheter trauma represents the most common etiology of iatrogenic aortic dissection. [21][22][23] The other possible causes can be summarized as follows:…”

Factors Affecting the Patient's Skin Dose During Percutaneous Coronary Intervention for Chronic Total Occlusion

“…The results have improved because of recent advances in technology and increased operator experience. [1][2][3][4][5][6][7] Recent studies show that successful PCI of a CTO is associated with improved survival; 8,9 however, the total fluoroscopic time (TFT) tends to be long in this procedure compared with PCI for non-CTO. 10 The patient's entrance skin doses (ESD) are higher 10,11 and severe skin injury can occur, so the physician must estimate the ESD in order to prevent radiation skin injuries during the procedure.…”