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Ann Thorac Surg 1996;62:1180-1182
© 1996 The Society of Thoracic Surgeons

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Case Report

Aortic Dissection Extending From the Left Coronary Artery During Percutaneous Coronary Angioplasty

Second Department of Surgery, Nippon Medical School, Tokyo, Japan

Accepted for publication April 11, 1996.

	Abstract

Top Footnotes Abstract Introduction Comment References

 
A 72-year-old woman with acute aortic dissection as a complication of percutaneous coronary angioplasty was successfully treated. She received a graft replacement of the ascending aorta as well as triple coronary artery bypass grafts. The dissection had extended from the left coronary artery. Although acute aortic dissection is a rare complication of percutaneous coronary angioplasty, physicians and cardiac surgeons should keep its potential occurrence in mind.

	Introduction

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Acute coronary artery dissection after percutaneous transluminal coronary angioplasty (PTCA) is an important complication that represents the most common indication for urgent bypass operation. We describe a case in which dissection that occurred in the left coronary artery during an angioplastic procedure extended beyond the coronary ostium into the entire ascending aorta.

A 72-year-old woman with a previous history of anterior myocardial infarction was referred to our institute because of unstable chest pain and an abnormal result on the stress test. Diagnostic coronary angiography revealed a 99% stenosis in the proximal segment of the left anterior descending coronary artery (LAD) with no significant lesion elsewhere. Subsequently, coronary angioplasty was indicated.

During the procedure, while the angiologists were manipulating a catheter, she experienced an abrupt onset of acute chest pain followed by ST-segment elevation on the electrocardiogram and hemodynamic deterioration. An angiogram taken after an application of the intraaortic balloon pump for hemodynamic stabilization showed dissection from the left main coronary artery to the LAD involving a major diagonal branch. The distal segment of the LAD could not be opacified. Furthermore, the contrast medium injected in the coronary artery went into the ascending aorta through the dissected lumen retrogradely beyond the coronary ostium up to the aortic arch (Fig 1). An additional aortic angiogram revealed there was no definite entry in the ascending aorta (Fig 2). At this time the angiologists recognized that the coronary dissection had extended to the ascending aorta. Intraaortic balloon pumping was discontinued because of aortic dissection, and the patient was transferred to the operating room.

View larger version (128K): [in this window] [in a new window]   Fig 1. . Preoperative angiogram of the left coronary artery. White arrows indicate coronary dissection. Black arrows indicate aortic dissection. Note the influx of the contrast medium from the coronary dissection into the aortic one (large black arrow).

View larger version (125K): [in this window] [in a new window]   Fig 2. . Preoperative aortogram, which indicates no definite intimal tear in the entire ascending aorta by showing no opacification of the dissection.

View larger version (33K): [in this window] [in a new window]   Fig 3. . Closure of the left coronary ostium to exclude coronary dissection from the aorta.

The patient was weaned from cardiopulmonary bypass without difficulty. She recovered uneventfully and was discharged on the 30th postoperative day. The postoperative angiogram showed patent bypass grafts. No false lumen was opacified on the aortogram.

	Comment

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Although the incidence of emergency operation after PTCA is low in many studies [1–3], surgical back-up has been generally advocated because of the potential risk of the procedure. Despite increasing technical sophistication, total coronary artery occlusion occurring during or immediately after PTCA remains a serious and not uncommon complication.

The need for an operation mainly arises from balloon catheter-induced dissection of a major coronary artery leading to significant myocardial ischemia [3]. Attempts have been made by physicians to manage such a complication, and in a number of cases this problem can be adequately treated by standard angioplasty techniques or devices such as bail-out stenting [4, 5] or directional atherectomy [6].

There have been 4 cases in the literature of aortocoronary dissection during the catheterization procedure. Geraci and colleagues [7] reported aortocoronary dissection complicating diagnostic coronary arteriography. In their report, however, the patient was treated with conservative management successfully.

Moles and associates [8] reported the first cases of aortic dissection as a complication of PTCA. Their 2 cases had different causes and evolutions. In their first case, the entry port was in the mid-LAD, and was protected from blood flow by the occlusion of the vessel. Because the dissection of the aorta was limited to the sinus of Valsalva, surgical intervention was not necessary for this case. In their second case, on the other hand, surgical management was necessary because the entry was in the aortic intima adjacent to the conal artery, leading to dissection of the ascending aorta.

A patient reported by Varma and co-workers [9], in whom right coronary dissection during PTCA extended into the aortic root, died in 48 hours with conservative treatment.

According to Geraci and colleagues [7] and Moles and associates [8], aortic dissection complicating PTCA might be self-limiting when it occurs from dissection of the coronary artery. In our case, however, the dissection had extended to the ascending aorta even though the entry port may have been the proximal portion of the LAD and was not exposed to the aortic bloodstream. It is possible that rather forceful, although inadvertent, injection of the contrast medium into the dissected coronary artery resulted in the progression of the dissection into the entire ascending aorta. Our patient denied either clinical evidence or family history of Marfan's syndrome or other causes of medial necrosis, although there is no histopathologic specimen.

Because the dissection had occurred first in the coronary artery, we placed a mattress suture around the left coronary ostium to isolate the coronary dissected lumen from the aortic one. Another possible procedure would have been ligation of the left main coronary artery from outside. The latter procedure, however, could have left the intimal tear proximal to the ligation, which may have led to the enlargement of the remaining dissected lumen of the proximal aorta. We confirmed there was no residual opacification of the dissected lumen in either aorta or coronary artery on the postoperative angiogram.

The number of patients receiving coronary intervention has grown rapidly. Aortic dissection during coronary angioplasty may occur secondary to contrast injection into the intimal tear that was created after balloon dilation. Surgical intervention is the only solution for this problem. Back-up surgeons should be aware of this serious complication.

	Footnotes

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Address reprint requests to Dr Ochi, Second Department of Surgery, Nippon Medical School, 1-1-5 Sendagi Bunkyo-ku, Tokyo, 113, Japan.

	References

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1. Steffenino G, Meier B, Finci L, et al. Acute complications of elective coronary angioplasty: a review of 500 consecutive procedures. Br Heart J 1988;59:151–8.[Abstract/Free Full Text]
2. Talley JD, Weintraub WS, Roubin GS, et al. Failed elective percutaneous transluminal coronary angioplasty requiring coronary artery bypass surgery. Circulation 1990;82:1203–13.[Abstract/Free Full Text]
3. Saatvedt K, Norstrand K, Vatne K, Geiran O, Lindberg H, Frøysaker T. Surgical intervention following failed percutaneous coronary angioplasty. Scand J Thorac Cardiovasc Surg 1993;27:9–13.[Medline]
4. Haude M, Erbel R, Straub U, Dietz U, Schatz R, Meyer J. Results of intracoronary stents for management of coronary dissection after balloon angioplasty. Am J Cardiol 1991;67:691–6.[Medline]
5. Maiello L, Colombo A, Gianrossi R, McCanny R, Finci L. Coronary stenting for treatment of acute or threatened closure following dissection after coronary balloon angioplasty. Am Heart J 1993;125:1570–5.[Medline]
6. Warner M, Chami Y, Johnson D, Cowley MJ. Directional coronary atherectomy for failed angioplasty due to occlusive coronary dissection. Cathet Cardiovasc Diagn 1991;24:28–31.[Medline]
7. Geraci AR, Krishnaswami V, Selman MW. Aorto-coronary dissection complicating coronary arteriography. J Thorac Cardiovasc Surg 1973;65:695–8.[Medline]
8. Moles VP, Chappuis F, Simonet F, et al. Aortic dissection as complication of percutaneous transluminal coronary angioplasty. Cathet Cardiovasc Diagn 1992;26:8–11.[Medline]
9. Varma V, Nanda NC, Soto B, et al. Transesophageal echocardiographic demonstration of proximal right coronary artery dissection extending into the aortic root. Am Heart J 1992;123:1055–7.[Medline]

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