Coronary artery dissection during PTCA: A necessary evil?

Abstract

The subject of coronary dissection resulting from the angioplasty process is addressed by a submission in the current issue entitled "Late Progression of an Asymptomatic Intimal Tear to Occlusive Coronary Artery, Dissection Following Angioplasty " [l]. In this communication the authors describe symptomatic delayed closure of a dissected artery within 1 month of angioplasty . Postangioplasty photographs indicate the usual sort of lesion change that may be commonly expected as a part of the angioplasty process. Their excellent photographs show us that the intimal tear or dissection occurred in the general area in which the balloon would have been inflated but distal to the visibly stenotic segment. Extension of the angioplasty dissection change was remote to the perioperative period and this is supported by the fact that the patient had an excellent treadmill response prior to dismissal from the hospital.The authors correctly cite the experience of the NHLBI Data Registry for PTCA that late closure of a vessel due to local dissection is extremely unusual after the initial '24-48 hr postoperative period [2]. Indeed, when early recurrence of angina is reported by a postangioplasty patient, the differential includes spasm, thrombosis, or local fibrocellular reaction with restenosis as being the more likely causes of late occlusion. The experience of most physicians actively involved in performing percutaneous transluminal coronary angioplasty supports the contention of the rarity of closure due to a progressive dissection.The authors review the mechanical and pathophysiologic changes that have been observed following successful angioplasty . The mechanism of such changes may include disruption or slippage of the intima, splitting of the media, stretching of the entire adventitia, and, in effect, a "recalibration" of the entire vessel lumen. It appears that the amount of luminal change due to compression of the plaque is probably minimal [3]. If the commonly recognized changes do not result in immediate closure of the vessel, it has been generally observed that a long-term favorable result can be expected more often than not, even when there is significant disruption or marked change in the lesion, with the appearance of the vessel showing significant lumen irregularity suggesting local tearing or in situ dissection [4]. Our early communication on this subject has been subsequently verified by the work of others [5]. Renkin's study supports our original contention of dissection being associated with a lower recurrence rate in that significant luminal disruption seems to enhance the healing process and careful follow-up of patients in our original series revealed that a

Fractional flow reserve‐guided paclitaxel‐coated balloon treatment for de novo coronary lesions

“…Post‐procedural QCA data confirmed this, as the balloon to artery ratio was 1.15 ± 0.16. These procedural attempts may result in dissection after balloon angioplasty compared to conventional practice of lesion preparation for stent, however, it is necessary to acquire adequate flow by plaque modification . In the present study, flow gain after POBA was demonstrated by successful angiographic results (70/80, 87.5%) and improvement of the mean FFR value in the study population from 0.67 ± 0.15 to 0.83 ± 0.08.…”

Late Coronary Spasm Complicating Successful Angioplasty of the Left Main Coronary Artery

“…Less ideal were the morphologic char acteristics of the lesion including irregulari ties and eccentricity features which carry a higher risk for dissection [4], Clearly, the result of the PTCA was considered satisfac tory showing a significant reduction in diam eter stenosis associated with abolishment of the transstenotic pressure gradient. The an giogram revealed an intimal tear associated with intraluminal haziness at the dilated seg ment, findings commonly observed after successful angioplasty [5], Recurrence of spontaneous angina pecto ris 48 h after PTCA was presumably due to a spasm at the LMCA angioplasty site. The presence of spontaneous changes in luminal diameter of the LMCA observed during the control angiogram leading to severe hemo dynamic deterioration and the fact that ni trates promptly reversed the situation, strongly support the concept of spontaneous spasm of the LMCA.…”