Aortocoronary Dissection Complicating Primary Angioplasty

From the Department of Cardiology, Freeman Hospital, Newcastle-Upon-Tyne, United Kingdom. The authors report no conflicts of interest regarding the content herein. Manuscript submitted January 31, 2009, provisional acceptance given March 24, 2009 and final version accepted April 7, 2009. Address for correspondence: Richard A. Brown, MBBS MRCP, Royal College of Physicians, 113 The Wills Building, Coast Road, Newcastle-Upon-Tyne, ne7 7rg, United Kingdom. E-mail: ric.brown@hotmail.co.uk

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J INVASIVE CARDIOL 2009;21:E145-E146 Case Presentation. A 57 year-old hypertensive male was transferred for primary percutaneous coronary intervention (PCI) following an index presentation of acute inferior myocardial infarction (MI). He was found to have a 99% stenosis of the right coronary artery (RCA) posterior descending arterial (PDA) branch. PCI was carried out via the right radial artery using a 6 Fr AL1 guiding catheter (Cordis Corp., Miami Lakes, Florida). Two drug-eluting stents were successfully deployed. After PCI of the culprit lesion, guidewire removal resulted in catheter-induced proximal dissection of the RCA. The dissection tracked proximally into the aorta and distally throughout the RCA. The RCA was re-engaged with a JR4 and floppy wire. We treated the RCA ostium using a Jo covered stent (Figure 1) and deployed 3 additional bare-metal stents throughout the proximal and mid-vessel, resulting in thrombolysis in myocardial infarction (TIMI) 3 flow (Figure 2). The patient remained pain-free and an echocardiogram performed at the time revealed trace aortic regurgitation and a tiny pericardial effusion. A subsequent computed tomographic (CT) chest scan showed no residual aortic dissection. The patient remained well and was discharged home after 4 days. Discussion. Ostial coronary dissection complicating PCI leading to acute dissection of the ascending aorta is a rare and life-threatening occurrence, with a frequency thought to be between 0.03–0.06%. RCA dissection is more common than left main stem dissection and is better tolerated. Patients in this clinical setting are at risk of acute MI, emergency surgery or sudden cardiac death.1 The appropriate therapy and outcome of this rare entity is not well established, although options may include surgery, conservative management or PCI, depending on the severity of the signs and symptoms. Surgery must be considered when aortic dissection occurs in the proximity of the coronary ostium. When the aortic dissection is small, good surgical results are obtained joining the edges of the injury with some suture stitches.2 Limited and stable dissections can be treated conservatively or by means of intraluminal stents. To treat an ostial coronary lesion, a stent must be delivered to the coronary ostium, protruding 1–2 mm into the aortic lumen, with the intention of sealing the aortic dissection.3 Another option is to stabilize the lumen of a dissected coronary artery with intracoronary stenting to seal the entry point and assess the extent of aortic dissection with serial noninvasive imaging. This may be even more effective with the availability of covered stents.4 Covered stents consist of two coaxially aligned stainless steel stents securing a polytetrafluoroethylene (PTFE) membrane between them in a sandwich-like manner and are thought by some interventionists to be preferable to standard stents, particularly when the entry site of a dissection is formed at the coronary ostia because they are more likely to completely seal the dissection.5

2. Mauser M, Enker J, Fleischmann D. Dissection of sinus Valsalvae aortae as a complication of coronary angioplasty (Summary). Z Kardiol 1999:88:1023–1027.

3. Rangel-Abundis A, Basave-Rojas MN, Albarrán-López H. Iatrogenic dissection of the right coronary artery and ascending aorta secondary to endoluminal angioplasty. A case report. Cirugia y Cirujanos 2005;73:207–210.

4. Goldstein JA, Casserly IP, et al. Aortocoronary dissection complicating a percutaneous coronary intervention. J Invasive Cardiol 2003;15:89–92.

5. Abu-Ful A, Weinstein JM, Henkin Y. Covered stent: A novel percutaneous treatment of iatrogenic aortic dissection during coronary angioplasty. J Invasive Cardiol 2003;15:408–409.