Iatrogenic Aortocoronary Dissection: The Case for Immediate Aortoostial Stenting

Assessing the impact of tear direction in coronary artery dissection on thrombosis development: A hemodynamic computational study

OBJECTIVE

Iatrogenic coronary artery dissection is a complication of coronary intimal injury and dissection due to improper catheter manipulation. The impact of tear direction on the prognosis of coronary artery dissection (CAD) remains unclear. This study examines the hemodynamic effects of different tear directions (transverse and longitudinal) of CAD and evaluates the risk of thrombosis, rupture and further dilatation of CAD.

METHODS

Two types of CAD models (Type I: transverse tear, Type II: longitudinal tear) were reconstructed from the aorto-coronary CTA dataset of 8 healthy cases. Four WSS-based indicators were analyzed, including time-averaged wall shear stress (TAWSS), oscillatory shear index (OSI), relative residence time (RRT), and cross flow index (CFI). A thrombus growth model was also introduced to predict the trend of thrombus growth in CAD with two different tear directions.

RESULTS

For most of the WSS-based indicators, including TAWSS, RRT, and CFI, no statistically significant differences were observed across the CAD models with varying tear directions, except for OSI, where a significant difference was noted (p < 0.05). Meanwhile, in terms of thrombus growth, the thrombus growing at the tear of the Type I (transverse tear) CAD model extended into the true lumen earlier than that of the Type II (longitudinal tear) model.

CONCLUSIONS

Numerical simulations suggest that: (1) The CAD with transverse tear have a high risk of further tearing of the dissection at the distal end of the tear. (2) The CAD with longitudinal tear create a hemodynamic environment characterized by low TAWSS and high OSI in the false lumen, which may additionally increase the risk of vessel wall injury. (3) The CAD with transverse tear may have a higher risk of thrombosis and coronary obstruction and myocardial ischemia in the early phase of the dissection.

Aortocoronary dissection during percutaneous coronary interventions for chronic total occlusion: Insights from the PROGRESS-CTO registry

BACKGROUND

Aortocoronary dissection is a potentially serious complication of chronic total occlusion (CTO) percutaneous coronary intervention (PCI).

METHODS

We examined the incidence, mechanisms, treatment, and outcomes of aortocoronary dissection among 12,117 CTO PCIs performed between 2012 and 2022 in a large multicenter CTO PCI registry.

RESULTS

The incidence of aortocoronary dissection was 0.2% (n = 27). Most aortocoronary dissections occurred in the right coronary artery (96.3%, n = 26). The baseline clinical characteristics of patients with and without aortocoronary dissection were similar, except for dyslipidemia, which was less common in patients with aortocoronary dissection (70.4% vs. 86.0%; p = 0.019). The retrograde approach was used more commonly among cases complicated by aortocoronary dissection (59.3% vs. 31.0%; p = 0.002). Technical (74.1% vs. 86.6%; p = 0.049) and procedural (70.4% vs. 85.2%; p = 0.031) success rates were lower among aortocoronary dissection cases, with a similar incidence of in-hospital major adverse cardiovascular events (3.7% vs. 2.0%; p = 0.541). Of the 27 patients with aortocoronary dissection, 19 (70.4%) were treated with ostial stenting and 8 (29.6%) were treated conservatively without subsequent adverse clinical outcomes. No patients required emergency surgery. Follow-up was available for 22 patients (81.5%): during a mean follow up of 767 (±562) days, the incidence of in-stent restenosis was 11.1% (n = 3).

CONCLUSIONS

Aortocoronary dissection occurred in 0.2% of CTO PCIs performed by experienced operators, was associated with lower technical and procedural success, and was treated most commonly with ostial stenting. None of the patients required emergency cardiac surgery.

Type A aortic dissection during therapeutic coronary intervention in acute coronary syndrome: case report

Iatrogenic aortic dissection during coronary interventions is a rare complication and has heterogeneous management in the reviewed literature. We report a case of acute aortic syndrome of traumatic etiology, during a percutaneous coronary procedure, with its management, intra-hospital evolution, and one-year follow-up. A 65-year-old female who, during a percutaneous coronary intervention, presented an endothelium trauma of the left main artery's aorta-ostial transition by the tip of the guide catheter, leading to aortic dissection and occlusion of the left main artery with hemodynamic deterioration of the patient. The left main artery's flow was restored with drug-eluting stent implantation leading to a successful sealing of the false lumen with consequent hemodynamic stabilization. Immediate post-procedure transthoracic echocardiography showed a competent aortic valve. The patient evolved favorably and remains asymptomatic after one year.

Iatrogenic Aortocoronary Dissection During Right Coronary Artery Procedures: A Systematic Review of the Published Literature

Iatrogenic aortocoronary dissection (IACD) occurs mainly during procedures involving the right coronary artery (RCA) and can result in disabilities, the need for urgent complex surgery, and even death. The risk factors for IACD are ill characterized, and the best management strategy is questionable; thus, there is a need to evaluate the characteristics, treatment options, and outcomes of patients with IACD of the RCA. We searched medical databases for publications on IACD of the RCA to present the characteristics of the procedures, management, and outcomes. We report 142 cases of IACD of the RCA, reported between 1973 and 2021. The mean age of the patients was 63.0 years, 81 (57%) were men, 75 (52.8%) presented with stable angina, and 29 (20.4%) had chronic total occlusion of the RCA. The most used catheter shapes were Judkins right (42%) and Amplatz left (25%), and most (56%) catheters were used during percutaneous coronary interventions. Guiding catheters were used in 38% (19/50) of diagnostic procedures when IACD occurred. A catheter size of ≤5F was used in only 3 cases. The catheter size was 6F in 22% of the cases, >6F in 23%, and not reported in 52%. A high-grade dissection (Dunning class III) occurred in 54% (77/142) of the cases. Stenting of the RCA ostium was performed in 88 (62%) of the cases, conservative treatment in 25 (18%), and surgery in 40 (28%) (aortic root repair [5%], coronary artery bypass grafting and aortic root repair [11%], and coronary artery bypass grafting alone [10%]). The mortality rate was 6.5% (5/77) among patients with class III dissection. Each patient should be considered independently. The most frequent intervention was to seal the dissection with a stent in the ostial RCA. However, in select cases published in the literature, a conservative approach was a feasible and successful option.

Iatrogenic aorta-coronary dissection: Case report and systematic review

OBJECTIVES AND BACKGROUND

Iatrogenic aorto-coronary dissection (ICD) is one of the most feared complications of interventional cardiology. Although rare, it is characterized by anterograde coronary ischemia and a concomitant aortic dissection, with potentially fatal consequences.

METHODS

We present an example case of IACD and an accurate case-series review of the literature including 125 published cases.

RESULTS

There were no significant predisposing factors and the IACD occurred equally in elective and urgent procedures. A significant number of IACDs were associated with CTO procedures. The factors associated with a worse outcome were hemodynamic instability, the presence of anterograde ischemia, and the extent of dissection according to the Dunning classification. Bail-out stenting was the most used strategy and its failure was associated with mortality.

CONCLUSION

The main features of IACD are anterograde ischemia, retrograde dissection, and hemodynamic instability, each of them should be addressed with no time delay, possibly with bailout stenting, the most employed exit-strategy. According to our proposed algorithm, a shock team approach is required to coordinate the interdisciplinary skills and enabled patients to receive the best treatment.

Spontaneous Early Resolution of an Iatrogenic Type A Aortic Dissection Following Coronary Angiography

A 74-year-old man was admitted with the diagnosis of non–ST-elevation myocardial infarction. During right coronary angiography, a coronary artery dissection extending into the proximal ascending aorta was noticed without hemodynamic compromise. Immediate computed tomography angiography showed no evidence of dissection in the ascending aorta. The patient remained hemodynamically stable with medical therapy alone. This case report highlights the importance of medical therapy in patients with uncomplicated iatrogenic aortic dissection.

A Practical Approach to the Percutaneous Treatment of Iatrogenic Aorto-coronary Dissection

Catheter-induced aortic dissection during coronary angiography and Percutaneous Coronary Intervention (PCI) is a relatively infrequent, but potentially life-threatening complication. Patients who suffer this complication may require emergency aortic surgery. More recently, reports of treating the ostium of the dissected coronary artery have emerged as an alternative therapeutic option. In this article we describe two cases of extensive guide catheter induced dissection and their successful treatment using PCI and provide a concise overview of the available literature.

Follow-up of iatrogenic aorto-coronary "Dunning" dissections by cardiac computed tomography imaging

Background

Iatrogenic aorto-coronary dissections following percutaneous coronary interventions (PCI) represent a rare but potentially life threatening complication. This restrospective and observational study aims to describe our in-house experience for timely diagnostics and therapy including cardiovascular imaging to follow-up securely high-risk patients with Dunning dissections.

Methods

Dunning dissections (DD) occurred during clinical routine PCIs, which were indicated according to current ESC guidelines. Diagnostic assessment, treatment and follow-up were based on coronary angiography with PCI or conservative treatment and cardiac computed tomography (cCTA) imaging.

Results

A total of eight patients with iatrogenic DD were included. Median age was 69 years (IQR 65.8–74.5). Patients revealed a coronary multi-vessel-disease in 75% with a median SYNTAX-II-score of 35.3 (IQR 30.2–41.2). The most common type of DD was type III (50%), followed by type I (38%) and type II (13%). In most patients (88%) the DD involved the right coronary arterial ostium. 63% were treated by PCI, the remaining patients were treated conservatively. 88% of patients received at least one cCTA within 2 days, 50% were additionally followed-up by cCTA within a median of 6 months (range: 4–8 months) without any residual.

Conclusion

Independently of the type of DD (I-III) it was demonstrated that cCTA represents a valuable imaging modality for detection and follow-up of patients with DDs.

Right coronary artery perforation extending to the coronary sinus of Valsalva during percutaneous intervention successfully sealed with polytetrafluoroethylene-covered stent: a case report

Background

Right coronary artery perforation extending to the sinus of Valsalva is a rare and potentially fatal complication of percutaneous coronary intervention. There are no definite guidelines on the management strategies for such complications. Treatment modality depends on the patient’s haemodynamic stability and the extent of aortic involvement. Polytetrafluoroethylene-covered stents have emerged as a revolutionary strategy, enabling efficient endovascular repair of the entry port of such dissections, particularly the coronary ostia, and obviating the need for high-risk emergent surgical intervention.

Case presentation

A 60 year old Bangladeshi gentleman underwent a coronary angiogram following a prior inferior ST elevation myocardial infarction (MI), 1 month previously. Coronary angiography done via right radial approach using 5 FR TIG catheter showed diffuse mid RCA disease with maximum 90% stenosis. Angioplasty of the RCA was planned. The RCA was cannulated with a 6-French JR 3.5 guiding catheter (USA). The lesion was crossed by a 0.014 inch guide wire and stented with a 2.75 × 38 mm novolimus-eluting DESyne stent, after predilatation. Immediately after stenting, a Type II perforation was observed in the ostial RCA, which progressed into the right coronary sinus of Valsalva. As the patient was haemodynamically stable with no ischaemia on ECG, we attempted to seal the ostial RCA with bare metal stents. Two successive bare metal stents failed to seal the aorto-coronary dissection. Ultimately, a 3.0 × 19 mm polytetrafluoroethylene-covered stent was deployed to seal the entry port in the ostial RCA, yielding a satisfactory angiographic result with only minimal contrast staining limited to the right sinus of Valsalva. The patient was closely monitored and discharged on dual antiplatelet therapy comprising of aspirin and prasugrel. He remained asymptomatic and with follow up echocardiograms showing no pericardial effusion nor extension of the dissection.

Conclusions

The polytetrafluoroethylene-covered stent provides a safe and effective means of sealing iatrogenic aorto-coronary dissections complicated by Ellis type II or II perforations, thus avoiding emergency surgery. However, as they are associated with increased incidence of stent thrombosis, an efficient and prolonged post-PCI antiplatelet regimen is recommended.

Electronic supplementary material

The online version of this article (10.1186/s13104-017-2867-3) contains supplementary material, which is available to authorized users.

Early Spontaneous Resolution of an Iatrogenic Acute Type A Aortic Dissection

Acute aortic dissection is a rare but devastating complication during cardiac catheterization. We present the case of an elderly female who incurred a Stanford Type A/DeBakey Type I acute aortic dissection extending into the arch vessels and descending aorta likely occurring during right coronary artery engagement for angioplasty. The patient was treated successfully by immediately sealing the entrance of the dissection via the placement of a stent and anti-impulse therapy. Follow-up computed tomography scan showed complete resolution of the dissection within one month.

Perioperative management for iatrogenic aortocoronary dissection during percutaneous coronary intervention

Aortocoronary dissection is a rare but serious complication. We report the case of a 72-year-old female with angina. Percutaneous coronary intervention was performed for right coronary artery disease. Manipulation of the guiding catheter led to aortocoronary dissection. A drug-eluting stent was immediately implanted in the right coronary ostium to seal the entry of the dissection. Computed tomography (CT) showed ascending aortic dissection. The patient was observed without surgery. CT performed the following day and showed the contrast in the false lumen which had disappeared. Clinicians are more likely to avoid surgical treatment if stenting successfully seals the entry of the coronary dissection.

Importance of IVUS in the treatment with retrograde approach of a long in-stent chronic total occlusion of ostial right coronary artery: A case report

A 43year-old male, with a long history of coronary artery disease, was electively admitted to our institution because of dyspnea for moderate physical efforts (NYHA 2) related to an in-stent chronic total occlusion of ostial RCA and with demonstration of a significant area of inducible myocardial ischemia at stress echocardiography. After a gentle attempt of antegrade approach, the in-stent CTO of ostial RCA was successfully reopened with a retrograde approach using a knuckle technique. After IVUS evaluation which showed that the course of the retrograde guidewire was mostly within the stent strut circumference with the exception of the ostial RCA where the guidewire past between the stent and the vessel wall, implantation of 4 drug-eluting stent was performed from mid to ostial RCA with a good final result. The hospital stay was uneventful. At 6months clinical follow-up the patient was in good clinical condition. We discuss some aspects related to procedural technique, the importance of IVUS evaluation in the treatment of this patient.

Aortic Dissection Caused by Percutaneous Coronary Intervention: 2 New Case Reports and Detailed Analysis of 86 Previous Cases

Aortic dissection, a rare sequela of percutaneous coronary intervention, can be fatal when it is not recognized and treated promptly. Treatment varies from conservative management to invasive aortic repair and revascularization. We report the cases of 2 patients whose aortic dissection was caused by percutaneous coronary intervention. In addition, we present detailed analyses of 86 previously reported cases. Aortic dissection was most often seen during intervention to the right coronary artery (in 76.7% of instances). The 2 most frequently reported causes were catheter trauma (in 54% of cases) and balloon inflation (in 23.8%). The overall mortality rate was 7.1%. We conclude that most patients can be treated conservatively or by means of stenting alone, with no need for surgical intervention.

Successful Aorta-osteal Stenting after Iatrogenic Acute Type-A Aortic Dissection during Primary Percutaneous Coronary Intervention

BACKGROUND

Iatrogenic acute dissection of the ascending aorta following coronary angiography and percutaneous intervention is rare. This complication, if not managed urgently, can have critical results.

CASE REPORT

We present the case of a 70 year-old woman who was treated by primary percutaneous coronary intervention (PCI) of the right coronary artery (RCA) for acute inferior myocardial infarction; however, the procedure was complicated by anterograde dissection of the RCA with a simultaneous retrograde propagation to the proximal part of the ascending aorta. Successful stenting of the entry point was able to heal the RCA and restrict the retrograde propagation to the ascending aorta. The aortic dissection was monitored by means of computerised tomography and the dissection repaired itself spontaneously within a day.

CONCLUSION

Treatment of the aorta coronary dissection (ACD) by urgent osteal stenting is a less invasive treatment compared with surgical treatment in appropriate cases. We demonstrated that immediate osteal stenting should be performed in ACD.

Frequency and outcomes of aortocoronary dissection during percutaneous coronary intervention of chronic total occlusions: a case series and systematic review of the literature

BACKGROUND

Aortocoronary dissection can complicate percutaneous coronary intervention (PCI) of chronic total occlusions (CTOs).

METHODS

We retrospectively examined the frequency and outcomes of aortocoronary dissection among 336 consecutive CTO PCIs performed at our institution between 2005 and 2012 and performed a systematic review of the published literature.

RESULTS

Aortocoronary dissection occurred in six patients (1.8%, 95% confidence intervals 0.7%, 3.8%). All aortocoronary dissections occurred in the right coronary artery (CTO target vessel in five patients and donor vessel in one patient). The baseline clinical characteristics of patients with and without aortocoronary dissection were similar. Compared to patients without, those with aortocoronary dissection were more likely to undergo crossing attempts using the retrograde approach (25% vs. 67%, P = 0.036) and experience a major complication (2.4% vs. 33.3%, P = 0.008). Technical and procedural success rates were similar in both groups. Of the six patients with aortocoronary dissection one underwent emergency coronary bypass graft surgery (CABG), four were treated with ostial stenting, and one was treated conservatively without subsequent adverse clinical outcomes. Systematic literature review provided 107 published cases of aortocoronary dissection during PCI, that occurred mainly in the right coronary artery (74.8%) and were treated with stenting (49.5%), emergency CABG (29%), or conservatively (21.5%).

CONCLUSIONS

Aortocoronary dissection is an infrequent complication of CTO PCI and although it can be treated with stents in most patients, it may infrequently require emergency CABG.

Treatment optimization of aortocoronary dissection as a complication after heart catheterization using coronary computerized tomographic angiography

We present the case of a 71-year-old patient with a chronic total occlusion of the right coronary artery (RCA) resulting in a retrograde aortic dissection as a complication of coronary intervention. Acute therapy consisted of coronary stent implantation into the proximal RCA to cover the dissection's entry. One day after, computed tomography-guided angiography revealed a progression of the intramural aortic hematoma with a residual dissection at the RCA ostium. Recurrent coronary angiography was performed to implant another stent covering the entry. Imaging at follow-up demonstrated complete coverage of the Dunning dissection and regression of the intramural aortic hematoma.

A case of delayed occlusive dissection of the right coronary artery during coronary intervention of the left anterior descending artery

Catheter-induced coronary artery dissection occurs rarely during selective coronary angiography but generally progresses to complete coronary occlusion. We present a case of delayed occlusive dissection of the right coronary artery during coronary intervention of the left anterior descending artery. Bailout stenting was employed to treat the giant hematoma quickly using a unique technique. The use of two guidewires created a high probability that the true lumen was selected, and aspiration of the hematoma with the microcatheter and indeflator effectively repaired a catheter-induced coronary artery dissection.

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.

Spontaneous resolution of iatrogenic dissection of the left main coronary artery extending to the thoracic and abdominal aorta

Iatrogenic coronary artery dissection extending to the ascending aorta is a rare complication of percutaneous coronary interventions. Coronary stent implantation is usually sufficient to control the injury. In this report we describe an unusual case of spontaneous resolution of both left main coronary artery and aortic wall dissection. The patient was not operated on due to the location of the initial tear in the distal part of the left main coronary artery. Moreover, in computed tomography (CT) thrombus formation in the false lumen of the dissected aorta was seen. The in-hospital course was uneventful. The last follow-up CT showed complete resolution of dissection.

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.

Anterior ECG changes following iatrogenic dissection of the right coronary artery into the aortic root: exclusion of left coronary obstruction with transoesophageal echocardiography

One of the most troublesome complications of percutaneous coronary intervention (PCI) or angiography is retrograde dissection of the artery into the aortic root. We report a case involving the right coronary artery (RCA) which was treated with prompt deployment of stents. Recurrent chest pain and ST segment elevation in V(2-4) mimicked the ECG appearance of acute anterior infarction and prompted concern that the dissection had extended to impair flow in the left coronary artery (LCA). Transoesophageal echocardiography (TOE) demonstrated that the aortic root dissection had been contained and that the LCA was not compromised.

Repair of iatrogenic aortic regurgitation following cardiac catheterization

Acute aortic regurgitation (AR) related to left cardiac catheterization is an exceedingly rare complication. Valve repair is the best therapeutic option in case of isolated AR. We report the successful repair of an aortic valve tear following cardiac catheterization. 

Migrating type A intramural hematoma after repair of an anomalous right coronary artery aortocoronary dissection with a covered stent

Iatrogenic aortocoronary dissection is a rare and potentially life-threatening complication of percutaneous coronary intervention (PCI). Prompt coronary stenting can stop progression and avoid the need for surgical intervention. Herein, we describe a case of migrating aortic intramural hematoma (IMH) after repair of an anomalous right coronary artery aortocoronary dissection with a covered stent.

[Extensive iatrogenic coronary dissection during coronary angioplasty: a series of 19 consecutive patients]

PURPOSE OF THE STUDY

Extensive coronary dissection is a rare complication of intraluminal angioplasty. We report a retrospective study of 19 patients who consulted in a general hospital without cardiac surgery.

PATIENTS AND METHODS

After consulting our coronarography and angioplasty database, we included the extensive coronary dissections (type D, E and F) in our study. The medical files of the selected patients were analysed.

RESULTS

Between January 2003 and March 2010, 19 coronary angioplasty (total: 2542) were complicated with extensive dissections (incidence 0,75%). For 62,3% of the patients, the dissection was related to the guiding catheter. Eleven patients had type A and B1 lesions. The dissections affected the right coronary artery for 16 patients, the left anterior descending coronary artery for two patients and the left main coronary artery for one patient. After angioplasty, a final TIMI flow 3 was obtained for only 11 patients. In nine cases, we observed a limited extension to the aorta that did not need a chirurgical intervention and had no influence on the prognosis. The complications were common, such as death (n=1), coronary bypass (n=2), myocardial infarction (n=8), cardiogenic shock (n=2) and circulatory assistance (n=2).

CONCLUSION

Extensive coronary dissection is a rare complication of angioplasty. The right coronary is the most frequent vessel concerned and an extension to aorta is usual. The treatment is usually based on sealing the entry with a coronary stent. The complications are common and serious and we did not find any predicting factors to extensive coronary dissections that are unpredictable.

[Iatrogenic dissection of the right coronary artery and the ascending aorta during coronary intervention]

Iatrogenic acute dissection of the ascending aorta following coronary angiography and percutaneous intervention is rare. The options for treatment are dictated by patient stability, nature of dissection of the coronary vessel, ability to restore the coronary circulation and extent of aortic dissection. Usually localized aortic dissections have been managed conservatively or treated by sealing the entry with a coronary stent. Extensive dissections may require a surgical intervention. We report the case of a 52-year-old man with iatrogenic dissection of the right coronary artery ostium and extension of the dissection to the ascending aorta during intraluminal angioplasty of an obstructive lesion in the first portion of the right coronary artery. The patient was managed conservatively without stenting (failure stenting of the right coronary artery) and without surgery. Aortic dissection was monitored by means of transesophageal echocardiography. Serial computed tomography scans demonstrated spontaneous resolution of the dissection. The evolution of the patient was satisfactory. Causes, frequency and treatment procedures of this iatrogeny are discussed.