A Time to Act and a Time to Watch: Severe Guide-Catheter Induced Proximal Coronary Dissection With Extensive Ascending Aorta and Arch Dissection, Managed by Immediate Coronary Stenting and Watchful Waiting

J INVASIVE CARDIOL 2017;29(9):E99-E100.

Key words: cardiac imaging, coronary dissection, complications

Upon wire withdrawal following apparently uncomplicated right coronary artery (RCA) stenting (2.5 x 30 mm Resolute drug-eluting stent (Medtronic) using a 6 Fr JR guide via right radial in a 75-year-old man, a dissection became evident, extending from the guide-catheter tip to the proximal stent edge (Figure 1A). This contributed to acute vessel closure, and propagated retrogradely and extensively into the aortic root (Figure 1B).

The RCA was rewired and the proximal vessel implanted with a 3.5 x 22 mm Integrity bare-metal stent (Medtronic) from the ostium to the original stent. The patient then achieved hemodynamic stability, with no further extension of the now large aortic dissection and mural hematoma. The patient was observed and the wire withdrawn, with stable angiographic appearance (Figures 1C, 1D). Computed tomography (CT) aortogram demonstrated an intimal flap extending from the proximal RCA to the aortic arch, with intramural hematoma but no extravasation of contrast (Figure 1E). An aberrant origin of the right subclavian artery was also demonstrated, arising as the distal-most branch of the aortic arch, taking a retroesophageal course.

The type A dissection was managed conservatively. Three months later, the patient remained well and CT demonstrated almost complete healing of the aortic dissection (Figure 1F). 

Catheter-induced aortic dissection is rare, and more common after interventional than diagnostic procedures.¹ It can often be managed conservatively with favorable outcomes,¹ in contrast to guideline recommendations for surgical management of spontaneous type A aortic dissections.² The aberrant right subclavian artery origin (arteria lusoria) encountered here occurs in approximately 0.5% of radial catheterization procedures and is associated with procedural difficulty,³ and may have contributed to the tendency for the observed guide-induced dissection. 

In this case, prompt stenting of the dissection entry flap allowed for stabilization and eventual healing of a severe catheter-induced aortic dissection, without resort to surgical intervention.

References

1.    Gomez-Moreno S, Sabate M, Jimenez-Quevedo P, et al. Iatrogenic dissection of the ascending aorta following heart catheterisation: incidence, management and outcome. EuroIntervention. 2006;2:197-202.

2.    Hiratzka LF, Bakris GL, Beckman JA, et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. J Am Coll Cardiol. 2010;55:e27-e129.

3.    Valsecchi O, Vassileva A, Musumeci G, et al. Failure of transradial approach during coronary interventions: anatomic considerations. Catheter Cardiovasc Interv. 2006;67:870-878.

From the ¹Department of Cardiology, Concord Hospital, University of Sydney, Australia; and ²Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, University of Sydney, Australia.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

Manuscript accepted February 22, 2017.

Address for correspondence: Prof Harry Lowe, Cardiology Department, Concord Hospital, Hospital Rd, Concord, Sydney, NSW, 2139 Australia. Email: h.lowe@bigpond.net.au