Subacutely progressed extensive aortic dissection complicated with catheter-induced dissection in left main coronary artery

Abstract

A 64-year-old man complaining of resting angina underwent emergent coronary angiogram and significant stenosis in the mid-left anterior descending artery was discovered. Although deployment of the drug-eluting Cypher stent relieved the stenosis, the guiding catheter accidentally induced coronary dissection in the left main coronary artery (LMCA). Then, deployment of another Cypher stent at the lesion successfully managed the complication. 20 days later, although asymptomatic, extensive aortic dissection was detected from the coronary sinus of Valsalva to the femoral artery. 64-Row multidetector computed tomography demonstrated that the dissection originated from the LMCA and retrogradely expanded to the aorta. This type of dissection is a rare complication related to coronary intervention and even in such a clinical setting, asymptomatic delayed progression of retrograde aortic dissection has not previously been reported to our knowledge.

Management of Patients With Coronary Artery Malperfusion Secondary to Type A Aortic Dissection

“…To date, the optimal treatment modality remains debated, and no clear guideline on the optimal approach exists because of the infrequency of the condition. In fact, several case reports were published [3,4] particularly after iatrogenic catheter-induced aortocoronary dissection [5,6], but only two larger case series reported their surgical methodology: Neri and colleagues [7] reported a series of 24 patients and advocated direct CA repair preferable to CA bypass grafting (CABG), whereas Kawahito and colleagues [8] reported a series of 12 patients and recommended CABG repair in all patients. In addition, some authors have called for the establishment of exclusion criteria for emergency operations in patients with CA malperfusion because of the low salvage rate [9].…”

Inadvertent left aorto-coronary dissection following percutaneous coronary intervention treated successfully by bail-out left main coronary artery stenting

“…8 The combination of improvements in PCI techniques, the advent of stents, and the use of glycoprotein IIb/IIIa inhibitors have increased the reports of successful percutaneous intervention in unprotected LMCA stenosis. 9 However, catheter-induced occlusive dissection of the unprotected LMCA extending to aortic sinus is quite rare following PCI. There are only a few reports of cases in which iatrogenic occlusive dissection of the LMCA following PCI which has been successfully revascularized percutaneously, 10 but nowhere, it was mentioned due to sudden removal of angioplasty balloon.…”

“…Percutaneous revascularization was preferred to CABG in order to re-establish the patency of the LMCA, LAD, and LCX more rapidly. 9 LMCA stenting enabled prompt restoration of the coronary blood flow before extensive myocardial necrosis developed. In fact, our patient had immediate cardiac arrest and he was resuscitated successfully.…”

Conservative management of left main dissection: Breaking the taboo

“…OCT technology provided confirmation that there were no additional uncovered entry points and accurate data about the length and size of the dissection plane. Stenting of such dissection may lead to shifting of the subintimal hematoma to the ascending aorta resulting in catastrophic long aortic dissections [3].OCT has emerged from a research tool to an invaluable intravascular imaging modality with excellent resolution allowing superior visualization of the vessel wall. With its increasing use in the everyday practice, we encounter new information with unclear clinical significance.…”

“…OCT technology provided confirmation that there were no additional uncovered entry points and accurate data about the length and size of the dissection plane. Stenting of such dissection may lead to shifting of the subintimal hematoma to the ascending aorta resulting in catastrophic long aortic dissections .…”