Iatrogenic left main coronary artery dissection

Iatrogenic coronary dissection: state of the art management

Iatrogenic coronary artery dissections (ICAD) are rare but potentially devastating complications during coronary angiography and percutaneous coronary interventions (PCI). Intima media complex separation may be produced either by the catheter tip or during PCI. Patient characteristics and procedure related risk factors are intimately linked to catheter induced ICAD over diagnostic angiography. Moreover, the increasing complexity of patients undergoing PCI, which frequently involves treatment of heavily calcified or occluded vessels, has increased the likelihood of dissections during PCI. A prompt recognition, along with a prompt management (either percutaneous, surgical or even careful watching), are key in preventing catastrophic consequences of ICAD, such as left ventricular dysfunction, cardiogenic shock, periprocedural myocardial infarction (MI) or cardiac death. This review aims to summarize the main updates concerning the pathophysiology, highlight key risk factors and suggest recommendations in management and treatment of ICAD.

Delayed percutaneous coronary intervention for an extensive iatrogenic left main coronary artery dissection: a case report

BACKGROUND

Iatrogenic left main coronary artery dissection is a rare but serious complication that can occur both during diagnostic coronary angiography and percutaneous coronary intervention. Early diagnosis and choice of optimal management are of crucial importance for patient's outcome while representing a challenge for clinicians.

CASE PRESENTATION

We present a case of iatrogenic left main coronary artery dissection occurring during diagnostic coronary angiography in a 53-year-old Greek woman with a history of coronary artery bypass grafting. Although dissection was greatly extending to mid left anterior descending artery, delayed percutaneous coronary intervention was successfully performed by carefully wiring the true lumen.

CONCLUSIONS

Delayed percutaneous coronary intervention, performed 25 days following the index event, proved to be a feasible and effective strategy for treating a widely extended left main coronary artery iatrogenic dissection.

Percutaneous Coronary Intervention for Iatrogenic Right Coronary Artery Dissection Post Bentall Procedure: A Case Report and Minireview

Iatrogenic coronary artery dissection is a potentially life-threatening complication of cardiovascular interventions. The optimal management of iatrogenic coronary artery dissection is not clear; however, both conservative management and percutaneous or surgical revascularization have been performed depending on the patient's clinical status and the extent of dissection. We present the first reported case of right coronary artery dissection after Bentall procedure performed for ascending aortic aneurysm. Urgent percutaneous intervention using adjunctive coronary imaging was performed with excellent clinical recovery. In this article, we highlight coronary artery dissection after Bentall procedure as a possible complication, provide an insight into various options in its management, and review published data on iatrogenic coronary artery dissection. We also discuss the challenges in percutaneous treatment of coronary artery dissection with special focus on intracoronary imaging for accurate diagnosis and guidance in the management of this complex lesion.

A catastrophic nightmare of the interventional cardiologist: Iatrogenic left main artery dissection and longitudinal stent deformation

Iatrogenic left main coronary artery dissection is a rare but potentially life-threatening complication of invasive coronary procedures. The newer generation drug eluting stents have shown a greater safety and efficacy compared to first generation drug eluting stents. We report a 60-year-old woman with iatrogenic left main coronary artery dissection who failed bailout stenting and underwent coronary artery bypass grafting. The strategy for managing left main coronary artery dissection is variable and depends upon the mechanism, the comorbidities of the patient and degree of hemodynamic stability. Longitudinal stent deformation is a rarely encountered complication but can be seen in complex lesions such as ostial, bifurcation and left main coronary artery lesions. The interventionists must be aware of this complication.

Successful Treatment of Occlusive Left Main Coronary Artery Dissection by Impella-Supported Stenting

We report successful treatment of a patient, who, during diagnostic angiography, developed an ostial left main coronary artery dissection with stump occlusion of the vessel. First, mechanical circulatory support with an Impella CP device was established. Then, patency of the left coronary system was achieved by placement of stents in the left anterior descending, left circumflex, and left main coronary arteries. On completion of the procedure, left ventricular systolic function, as assessed by echocardiography, was normal. At 24-month clinical follow-up, the patient remains angina-free and well. This is the first reported case of the use of an Impella device to support treatment of iatrogenic left main coronary artery dissection.

Repeat Coronary Artery Dissection in Pregnancy: A Case Report and Review of the Literature

Non-atherosclerotic spontaneous coronary artery dissection (NA-SCAD) is a rare cause of morbidity and mortality with a propensity for young, healthy, and often peripartum women. NA-SCAD etiology is poorly understood, with possible hormonal and hereditary mechanisms. Current treatment strategies range from conservative management (often showing resolution on angiographic follow-up) to invasive angiographic procedures. Rarely, NA-SCAD has recurred in another coronary artery, ranging hours to years later. We report NA-SCAD of the right coronary artery (RCA) in a 30-year old, 3-month postpartum female with an additional autopsy finding of remote myocardial infarction (MI) in the left anterior descending (LAD) coronary artery territory. The remote MI is consistent with prior NA-SCAD of the LAD and, given the medical history, may have occurred in the peripartum period of the decedent first pregnancy 3 years earlier. As such, to the best of our knowledge, this may represent the first reported case of NA-SCAD recurrence in a subsequent pregnancy.

Emergency Coronary Artery Bypass Graft Surgery for Iatrogenic Left Main Coronary Artery Dissection

Iatrogenic coronary artery dissection during coronary angiography with or without rupture is a rare but feared complication. We herein report a case of iatrogenic left main coronary artery dissection in a 49-year-old female. Admitted to our hospital with a recent history of severe hypotension, she develpled apnea during angiography. She was intubated and resuscitated with an Epinephrine infusion in the Cath-Lab. The diagnosis was iatrogenic left main coronary artery dissection based on angiography. Immediately, the patient was transferred to the operating room in a lethargic state with an Epinephrine infusion and prepared for emergency coronary artery bypass graft surgery. In the ICU, she was completely alert with no hemodynamic complications and finally was discharged in a good overall condition. At 18 months' follow-up, the patient was in a stable situation with good daily function.

Iatrogenic Aorto-Coronary Dissection Successfully Treated With IVUS Guided Unprotected Left Main Stenting: Case Report and Review of Literature

A 52-year-old male underwent cardiac catheterization for abnormal stress test. Trans-radial coronary angiography revealed a severe proximal left anterior descending artery (LAD) lesion. LAD angioplasty was performed with two drug-eluting stents. This resulted in dissection of the proximal LAD, the circumflex artery and the left main coronary artery (LMCA) extending back into the coronary sinus. A diagnosis of type 3 coronary dissection was made. The circumflex artery and the left coronary artery were stented, and then the LMCA was stented. Repeat intravascular ultrasound showed resolution of the dissection and TIMI-3 flow was achieved in all vessels. He underwent follow-up angiography in 1 month, which revealed patent stents with resolution of the aorto-coronary dissection. We report a rare case of iatrogenic aorto-coronary dissection that was successfully treated with unprotected left main percutaneous coronary intervention strategy alone and review the pertinent literature.

Conservative treatment of iatrogenic left main coronary artery dissection: report of two cases

Revascularization treatment is mostly recommended for iatrogenic left main coronary artery dissection because of potential for catastrophic sequel, even in case of initial TIMI 3 flow and hemodynamic stability. However, conservative treatment seems to be feasible in asymptomatic and hemodinamically stable patient with low-grade dissection. We report two cases of iatrogenic left main coronary dissection managed conservatively.

Left main dissection conservatively managed with optical coherence tomography guidance

Left main dissection (LMD) is a rare but feared complication of cardiac catheterization. It is usually managed by bailout stent implantation or coronary artery bypass surgery. We describe a case of iatrogenic, retrograde LMD during percutaneous coronary intervention. After covering the retrograde entry of the dissection in the ostial left anterior descending artery (LAD), optical coherence tomography (OCT) showed, that there was no antegrade entry in the left main and that the minimal true lumen area in the left main was 7.2 mm(2) . It was therefore decided to treat the LMD conservatively and reassess the results by angiography 6 months later. At follow-up angiography, no stenosis or residual dissection in the left main were noted. The patient was doing fine at 1-year follow-up. OCT is a valuable tool for assessing coronary artery dissections and may guide the decision, whether to stent or not to stent a dissection. In selected cases LMD may be managed conservatively.