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Ann Thorac Surg 1995;59:585-590
© 1995 The Society of Thoracic Surgeons

Coronary Artery Disease in Patients With Type A Aortic Dissection

Division of Cardiothoracic Surgery, Department of Surgery, Barnes Hospital and The Jewish Hospital of St. Louis, Washington University, St. Louis, Missouri

Accepted for publication October 19, 1994.

	Abstract

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
The usefulness of preoperative coronary arteriography in patients with type A dissection of the aorta is controversial. To determine the prevalence of arteriosclerotic coronary artery disease in patients with type A dissection of the aorta, we reviewed our experience in 62 patients (42 with acute dissection and 20 with chronic dissection) who underwent operation between January 1, 1986, and December 31, 1993. Among 23 patients with acute dissection who underwent coronary arteriography, 8 (34.8%) had one or more coronary artery lesions causing a greater than 50% narrowing. Among 14 patients with chronic dissection who underwent coronary arteriography, 6 (42.9%) had one or more coronary artery lesions causing a greater than 50% narrowing. There were no fatal complications associated with coronary arteriography. Four patients with acute dissection and 6 patients with chronic dissection underwent coronary artery bypass grafting at the time of operative repair of the aortic dissection, with no operative deaths. On the basis of these findings and the success of combined coronary artery bypass grafting and aortic repair, we recommend that patients with an acute type A dissection who are in stable condition and all patients with a chronic type A dissection of the aorta should undergo preoperative coronary arteriography.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
See also page 590.

Aortography has traditionally been the cornerstone in the diagnosis of aortic dissection. This technique is useful for delineating the extent of the dissection process and for gauging the extent to which the dissection process involves the proximal coronary arteries and great vessels. In cases of aortic dissection involving the ascending aorta, aortography can also be useful because it facilitates selective coronary arteriography, which can be used to evaluate the distal coronary arteries and help determine the appropriateness of concomitant coronary artery bypass grafting (CABG). Recently, however, several less invasive diagnostic techniques have been enjoying increasing popularity as tools for establishing the diagnosis of aortic dissection; these include computed tomography (CT), magnetic resonance imaging (MRI), and transesophageal echocardiography (TEE) [1–9]. All of these less invasive techniques are capable of sufficient diagnostic accuracy to obviate the need for aortography in some cases, but they do not provide information about arteriosclerotic disease of the distal coronary arteries.

The present study was undertaken to determine the prevalence of arteriosclerotic coronary artery disease in a contemporary series of patients undergoing operation for the treatment of acute and chronic type A dissection of the aorta. As a secondary goal of this study, the utility of the commonly used preoperative diagnostic studies for the evaluation of patients with type A dissection of the aorta was assessed.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
Clinical Material
Between January 1, 1986, and December 31, 1993, 62 patients at the Washington University Medical Center (Barnes Hospital, St. Louis Children's Hospital, and The Jewish Hospital of St. Louis) underwent operation for the treatment of type A dissection of the aorta. For the purpose of this study, any dissection involving the ascending aorta was considered a type A dissection [10]. The study population consisted of 42 patients (67.7%) with acute dissection (<14 days [11]) and 20 patients (32.3%) with chronic dissection of the aorta. Data pertaining to each patient's medical history were gathered retrospectively at the time of discharge from the hospital. Variables included age; sex; a history of myocardial infarction, smoking, peripheral vascular disease, diabetes mellitus, or hypertension; the operation performed; the occurrence of perioperative myocardial infarction; and postoperative outcome. Patients with traumatic or intraoperative iatrogenic aortic dissection were excluded from analysis. The overall characteristics of the study population are summarized in Table 1.

The surgical procedures were performed by 11 different attending surgeons who used a variety of techniques [12] for the operative repair (Table 2) and for myocardial and cerebral protection. Among the patients with an acute type A dissection, CABG was performed in 11: in 7 for involvement of the proximal coronary arteries by the dissection process and in 4 for arteriosclerotic disease of the midcoronary to distal coronary arteries. Among the patients with a chronic type A dissection, CABG was performed in 8: in 2 for involvement of the proximal coronary arteries by the dissection process and in 6 for arteriosclerotic disease of the midcoronary to distal coronary arteries.

	Results

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
Coronary Artery Disease
The extent of arteriosclerotic coronary artery disease for the subset of patients undergoing preoperative coronary arteriography is summarized in Table 3. Among the 23 patients with an acute type A dissection who underwent coronary arteriography, 15 patients (65.2%) were found to have no arteriosclerotic coronary artery disease. Coronary artery disease was found in 8 patients (34.8%): in 6 with single-vessel disease and in 2 with three-vessel disease. Among the 14 patients with a chronic type A dissection who underwent coronary arteriography, 8 patients (57.1%) were found to have no arteriosclerotic coronary artery disease. Coronary artery disease was found in 6 patients (42.9%): in 1 with single-vessel disease, in 4 with two-vessel disease, and in 1 with three-vessel disease. On the basis of these findings, 4 patients with an acute type A dissection and 6 patients with a chronic type A dissection underwent CABG for the treatment of arteriosclerotic coronary artery disease at the time of operative repair of the aortic dissection. An additional 9 patients (7 with acute dissection and 2 with chronic dissection) underwent CABG because of involvement of the proximal coronary arteries by the dissection process.

Diagnostic Modalities
Our experience with the use of the common radiologic studies in this series of patients is summarized in Table 6. Among the patients with an acute type A dissection, the most commonly used radiologic study was aortography, performed in 38 of 42 patients (90.5%). Computed tomography, MRI, and echocardiography (both transthoracic and transesophageal) were used less commonly. Aortography achieved the greatest diagnostic accuracy in terms of establishing the diagnosis of an acute type A dissection (89.5%). The diagnostic accuracy was somewhat less for CT, MRI, and TEE, ranging between 75.0% and 80.0%. Transthoracic echocardiography was the least useful diagnostic study, with a false negative result in all patients (9 of 9) who underwent this study.

	Comment

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
Aortic dissection is diagnosed in more than 60,000 patients each year in the United States [13]. The incidence of type A dissection of the aorta ranges between 5 and 10 per one million population. Based on the mortality rates of 20% at 24 hours and 90% at 3 months shown by natural history studies, surgical repair of the aorta has become the standard therapy for patients with either acute or chronic type A dissection of the aorta [14]. During the past 40 years, an increasing awareness of the success of surgical therapy together with an increasing availability of diagnostic tools have facilitated the process of early diagnosis and referral, and the operative mortality associated with these procedures has decreased considerably, to less than 20% in most recently reported series [6, 8, 15–22].

Several diagnostic studies are useful for the evaluation of patients with aortic dissection. The chest radiogram findings are abnormal in as many as 90% of the patients with a type A dissection [23, 24]. The electrocardiogram findings are not specific, but may be abnormal in more than one third of the patients [22]. With a diagnostic accuracy reported to approach 99% and a false negative rate of less than 2%, the mainstay in the diagnosis for aortic dissection has traditionally been aortography [1, 8, 25, 26]. This technique can demonstrate both direct evidence of an aortic dissection, including an intimal flap and the presence of two or more lumens, and indirect evidence of an aortic dissection, including aortic insufficiency, abnormalities of the arch vessels, thickening of the aortic wall, and an abnormal catheter location. Although aortography can be performed safely in most patients, potential complications include cardiac arrest, precipitated by the administration of contrast agents, and perforation of the aorta, especially in patients with acute dissection. This technique can delineate the nature of the involvement of the proximal coronary arteries by the dissection process and can facilitate the performance of subsequent selective coronary arteriography. Although the addition of coronary arteriography prolongs the procedure only slightly, some arteriographers have been reluctant to perform this additional procedure routinely because of the risk of perforating the aortic wall with pointed coronary angiography catheters. This risk has not been fully documented, however.

Recently, there has been increasing enthusiasm for the use of several less invasive diagnostic tests for the purpose of establishing the diagnosis of aortic dissection; these tests include CT, MRI, and echocardiography [1–9, 25]. With the intravenous administration of contrast agents, the diagnostic accuracy of CT is reportedly more than 80% [1]. Magnetic resonance imaging can be useful for demonstrating the presence of an intimal flap and the presence of more than one lumen [4], and can be used to evaluate the aorta in any desired imaging plane, including the longitudinal plane along the course of the aorta. Most recently, TEE has been used to demonstrate the presence of an aortic flap. This test can also be used to identify the associated conditions of aortic insufficiency-aortic thrombus, pericardial effusion, and ventricular wall motion abnormalities. With the advent of multiplanar imaging probes, the diagnostic accuracy of this technique has been reported to approach 100% [6, 7]. Because the information obtained by TEE can be so accurate, a growing number of surgeons feel comfortable proceeding directly to operation without the benefit of coronary arteriography. However, although TEE can sometimes identify involvement of the proximal coronary arteries by the dissection process, none of these noninvasive diagnostic tests can provide information about the distal coronary arteries.

Our experience with the diagnostic techniques available confirms the findings of other investigators. In part, our apparent reliance on aortography instead of TEE stems from the fact that TEE has only recently become available. The greatest diagnostic accuracy, in terms of the diagnosis of either acute or chronic aortic dissection, was obtained with aortography, which achieved a true positive rate of approximately 90%. In our experience, CT, MRI, and TEE are capable of somewhat less diagnostic accuracy, but have the advantage of being less invasive than aortography. Although TEE is reported to have the additional ability to identify segmental wall motion abnormalities related to regional myocardial ischemia, no such abnormalities were identified in our patients. Traditional transthoracic echocardiography was performed in a substantial number of patients, both with acute and chronic dissection, but failed to identify the aortic dissection in any. It may be useful, however, in identifying or excluding other possible diagnoses such as valvular heart disease in the patient who presents with chest pain.

Among the patients in the present study who underwent coronary arteriography, there was a substantial prevalence of coronary artery disease. The prevalence (34.8% for patients with acute dissection and 42.9% for patients with chronic dissection) was somewhat higher than those previously reported by others (5% to 16%) [27]. The frequency with which concomitant CABG was performed for the treatment of arteriosclerotic coronary artery disease in the present study (4 of 23 patients with acute dissection and 6 of 14 patients with chronic dissection who underwent coronary arteriography) is similar to rates reported previously [28]. Unfortunately, none of the natural history studies performed so far have examined the eventual need for CABG or coronary angioplasty among patients who have undergone operation for the repair of a type A aortic dissection without preoperative assessment of the coronary arteries.

Among the study population, 4 patients with acute dissection and 6 patients with chronic dissection underwent CABG for the treatment of arteriosclerotic coronary artery disease at the time of aortic repair. This is obviously a minority of the patients in both groups. Nonetheless, the short-term outcomes in these patient groups were quite favorable. With no operative deaths and no perioperative myocardial infarctions occurring in this group of patients with a mean age exceeding 72 years, concomitant CABG appears to be a particularly worthwhile undertaking in those patients with identifiable coronary artery disease. Indeed, the operative mortality and incidence of perioperative myocardial infarction were considerably greater for those patients who did not undergo coronary arteriography.

Some authors have suggested that intraoperative coronary angioscopy may be useful for evaluating the extent of arteriosclerotic coronary artery disease in patients who have not undergone coronary arteriography preoperatively [29]. The ability of this technique to evaluate the coronary arteries, however, is limited to the proximal segments of the coronary arteries. Moreover, this technique is currently experimental and not widely available. As a result, there is limited experience with the interpretation of the data yielded by this study.

It has been suggested that, in urgent situations or when ventricular wall motion abnormalities are not detected by TEE, coronary arteriography can be omitted in patients with an acute type A dissection of the aorta. The results of the present study suggest, however, that coronary artery disease may remain undiagnosed if these patients do not undergo selective coronary arteriography. It is particularly important to identify coronary artery disease in these patients because of the implications regarding myocardial preservation, the potentially increased risk of perioperative myocardial infarction, and the potential need for eventual CABG in a then difficult reoperative setting. In our series, the operative mortality associated with combined repair of a type A aortic dissection and CABG was less than that associated with aortic repair alone. Therefore, because the morbidity and mortality associated with combined CABG and operative repair of the aorta are acceptable, we recommend that most patients with an acute type A aortic dissection undergo selective coronary arteriography before operation, unless the patient's critical condition dictates otherwise. This is particularly true for patients older than 50 to 55 years. For patients with a chronic type A aortic dissection, the decision to perform coronary arteriography is less difficult. We recommend that all patients with chronic dissection undergo a thorough diagnostic evaluation, including aortography and coronary arteriography.

	Acknowledgments

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
We thank Theresa M. Hildebrandt, Tina L. Burmeister, Patricia A. Lock-Buckley, and Suzan Murphy, RN, for data entry and retrieval, and Richard D. Schuessler, PhD, for statistical consultation.

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
Address reprint requests to Dr Rosenbloom, Division of Cardiothoracic Surgery, Washington University School of Medicine, 3108 Queeny Tower, St. Louis, MO 63110.

	References

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Lawrence L. Creswell Nicholas T. Kouchoukos James L. Cox Michael Rosenbloom Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Creswell, L. L. Articles by Rosenbloom, M. Search for Related Content PubMed PubMed Citation Articles by Creswell, L. L. Articles by Rosenbloom, M. Related Collections Related Article