Intimal Detachment of the Left Main Coronary Artery in a Marfan Patient with Acute Aortic Dissection: An Alternative Technique for Coronary Revascularization

Utility of ECG-Gated CTA for Detecting and Classifying Coronary Artery Involvement in Patients With Type A Aortic Dissection and Sinus of Valsalva Involvement

Background: Extension of type A aortic dissection (TAAD) from the sinus of Valsalva (SV) into the coronary arteries is associated with worse prognosis and requires direct coronary repair or coronary artery bypass graft (CABG) depending on extent of involvement. Objectives: To assess the diagnostic performance of ECG-gated aortic CTA for detection and classification of coronary artery involvement in patients with TAAD involving the SV, using surgical findings as reference. Methods: This retrospective study included 112 patients who underwent preoperative ECG-gated aortic CTA demonstrating TAAD with SV involvement. Two radiologists independently reviewed CTA images for right coronary artery (RCA) and left coronary artery (LCA) involvement. Involvement was classified using a previously described system as type A (coronary ostial dissection), B (dissection with coronary false channel), or C (complete detachment from aortic root with dissection encircling the coronary artery). Diagnostic performance of CTA was calculated using surgical findings as reference, interreader agreement was assessed, and surgical interventions were summarized. Results: At surgery, the RCA was uninvolved in 33 patients and exhibited type A, B, and C involvement in 45, 19, and 15 patients, respectively; the LCA was uninvolved in 70 patients and exhibited type A, B, and C involvement in 34, 8, and 0 patients, respectively. For the two readers, sensitivity in RCA, was 86.7%-91.1% for type A, 79.0%-89.5% for type B, 86.7%-93.3% for type C, and 97.5%-98.7% for any involvement. Sensitivity in LCA was 85.3%-91.2% for type A, 87.5%-100.0% for type B, and 100.0%-100.0% for any involvement. Specificity was, in RCA, 94.0%-97.0% for type A, 95.7%-96.7% for type B, 96.9%-96.9% for type C, and 93.9%-97.0% for any involvement. Specificity was, in the LCA, 96.2%-98.7% for type A, 96.2%-97.1% for type B, and 97.1%-98.6% for any involvement. Interreader agreement for types of involvement ranged from kappa=0.85-0.96. Most common intervention was aortic repair for SV involvement alone (55.7%-63.6%), coronary artery repair for types A and B (53.3%-87.5%), and CABG for type C (86.7%). Conclusions: ECG-gated CTA has high diagnostic performance for detecting and classifying coronary involvement from TAAD with SV involvement. Clinical Impact: CTA findings may help guide presurgical planning in these patients.