Ann Thorac Surg 2001;72:922-924
© 2001 The Society of Thoracic Surgeons
Case report
Glue aortoplasty repair of aortic dissection after coronary angioplasty
Alsir A.M. Ahmed, FRCSa,
Vaikom S. Mahadevan, MRCPb,
Samuel W. Webb, FRCPb,
Simon W. MacGowan, FRCSI (CTh)a,b
a Cardiac Surgical Unit, Royal Victoria Hospital, Belfast, Northern Ireland, United Kingdom
b Regional Medical Cardiology Centre, Royal Victoria Hospital, Belfast, Northern Ireland, United Kingdom
Accepted for publication September 22, 2000.
Address reprint request to Mr MacGowan, Cardiac Surgical Unit, The Royal Victoria Hospital, Grosvenor Rd, Belfast BT12 6BA, Northern Ireland
e-mail: simon.macgowan{at}royalhospitals.n-i.nhs.uk
 |
Abstract
|
|---|
Aortic dissection complicating percutaneous transluminal coronary angioplasty is rare. We report the case of a 45-year-old man who after right coronary artery angioplasty with stenting, dissected that vessel to involve the aorta to the bifurcation. Surgical repair with Gelatin-Resorcinol-Formaldehyde (GRF) glue as opposed to prosthetic graft replacement of the ascending aorta was successful. The use of GRF glue is effective in the surgical treatment of aortic dissection after coronary angioplasty.
|
Introduction
|
|---|
Aortic dissection complicating percutaneous transluminal coronary angioplasty is rare. Surgical repair with Gelatin-Resorcinol-Formaldehyde (GRF) glue is an alternative to prosthetic graft replacement of the ascending aorta can be successful and is effective in the surgical treatment of aortic dissection after coronary angioplasty.
A 45-year-old man who presented with symptoms of class II angina was admitted for cardiac catheterization and percutaneous coronary angioplasty with stenting of a tight proximal lesion of the right coronary artery (RCA). Three weeks previously he had a successful stenting of the first obtuse marginal branch of the circumflex coronary artery. Initially the procedure was uneventful with placement of a JR4 guide catheter followed by a High Torque Floppy wire (Cordis Corporation, Miami, FL) across the stenosis which was predilated with a 3.0 mm x 20 mm Maxxum balloon (Boston Scientific, Natick, MA). Subsequent contrast injection revealed a linear dissection arising from the proximal RCA. A 3.5 mm x 15 mm AVE S 670 stent (Medtronic AVE; Medtronic, Minneapolis, MN) was deployed in the area of the dissection with good vessel patency. However, despite the deployment of a further stent, the dissection extended further proximally in the RCA with a small flap visualized in the aorta near the ostium. Subsequent images showed the contrast extending into the ascending aorta up to the aortic arch (Fig 1). The patient remained clinically stable without any electrocardiogram changes. But due to the extent of the aortic dissection, combined with the involvement of the RCA ostium, he was referred for an operation. Transesophageal echocardiography confirmed the dissection to be extending from the ascending aorta down to the aortic bifurcation with mild aortic incompetence.
View larger version (21K):
[in this window]
[in a new window]
|
Fig 1. Line drawing of the coronary angiogram showing the dissection extending from the proximal right coronary artery along the wall of the ascending aorta.
|
|
Hypothermic cardiopulmonary bypass was instituted through a median sternotomy with left femoral artery and right atrial cannulation. There was no blood in the pericardial cavity. It was possible to place the cross clamp just proximal to the innominate artery. The aorta was opened through a standard transverse aortotomy about 2 cm above the ostium of the RCA. The right and anterior walls of the ascending aorta were found to be dissected into the aortic arch. The interior of the aorta both proximally and distally was carefully examined; no entry point was found in the aortic intima. This was corroborated by the sequence of events seen at angiography. The proximal right coronary artery was then dissected free from the surrounding tissues at its origin outside the aorta and ligated flush with the aortic wall. Another ligature was placed just distal to the stents to exclude the entry point in the proximal RCA. Gelatin-Resorcinol-Formaldehyde glue (Microval, Malmont, France) was applied as recommended by the manufacturer’s instructions both proximally and distally between the two dissected layers of the aorta. An endotracheal tube with the cuff inflated compressed the layers of the aortic wall distally while digital compression approximated the walls proximally. Care was taken to avoid spillage. The glue was allowed to set and the aortotomy closed primarily. The RCA was grafted with a reversed segment of saphenous vein. The proximal anastomotic site for the vein graft was fashioned with a standard 4.4 mm aortic wall punch and reinforced with a further application of GRF glue between the dissected layers. The resulting piece of aortic tissue was sent for histological examination. Bypass was discontinued with ease and the chest was closed in the normal fashion.
The postoperative course was unremarkable and the patient was discharged on the ninth postoperative day. Postoperative transesophageal echocardiography showed trivial aortic regurgitation but no residual dissection in the ascending aorta. Histological examination revealed cystic medial necrosis of the aortic wall. Subsequent computed tomography scans have shown a residual lumen in the distal thoracic and abdominal aorta, which will require routine surveillance. The ascending aorta and aortic arch were free from dissection.
|
Comment
|
|---|
Aortic dissection following percutaneous coronary intervention is a rare complication with few patients being reported in the literature. Most patients have been managed conservatively [1–3], with an operation being advocated for more extensive dissection [3, 4]. An operation usually involves replacement of the ascending aorta with possible reimplantation of the coronary arteries. No report has previously documented the use of GRF glue to repair such an injury. In this patient the indication for an operation was the extent of the dissection to the aorta coupled with concern about the patency of the proximal RCA. Glue aortoplasty was felt to be appropriate in this patient because there was no discernible entry site in the aorta. The histological examination of the aortic wall did show cystic medial necrosis, which explains an extensive aortic dissection in an otherwise uneventful procedure. Gelatin-Resorcinol-Formaldehyde glue is a water-based mixture of gelatin and resorcinol, which is activated by adding a hardener containing formaldehyde and glutaraldehyde, and the technique is well described in the management of aortic dissection [5, 6]. Because GRF glue is not available in the United States, it is possible that alternative biological glues may be as efficacious in the treatment of this condition. In selected patients with acute aortic dissection complicating percutaneous transluminal coronary angioplasty, glue aortoplasty as opposed to interposition graft replacement of the ascending aorta or conservative treatment is an effective option.
|
References
|
|---|
-
Geraci A.R., Krishnaswami V., Selman M.W. Aortocoronary dissection complicating coronary arteriography. J Thorac Cardiovasc Surg 1973;65:695-698.[Medline]
-
Bae J.H., Kim K.B., Kim K.S., Kim Y.N. A case of aortocoronary dissection as a complication during a percutaneous transluminal coronary angioplasty (PTCA). Int J Card 1998;66:237-240.[Medline]
-
Moles V.P., Chappuis F., Simonet F., et al. Aortic dissection as complication of percutaneous transluminal coronary angioplasty. Cathet Cardiovasc Diagn 1992;26:8-11.[Medline]
-
Pande A.K., Gosselin G., Leclerc Y., Leung T.K. Aortic dissection complicating coronary angioplasty in cystic medial necrosis. Am Heart J 1996;13:1221-1223.
-
Carpentier A. "Glue Aortoplasty" as an alternative to resection and grafting for the treatment of aortic dissection. Semin Thorac Cardiovasc Surg 1991;3:213-214.[Medline]
-
Borst H.G., Laas J., Buhner B. Efficient tissue gluing in aortic dissection. Eur J Cardiovasc Surg 1994;8:160-161.
This article has been cited by other articles:
|
|
|
|
 
C. Tanasie, M. Chandonnet, A. Chin, A. Kokis, H. Ly, L. P. Perrault, and C. Chartrand-Lefebvre
Catheter-Induced Aortic Dissection After Invasive Coronary Angiography: Evaluation With MDCT
Am. J. Roentgenol.,
December 1, 2011;
197(6):
1335 - 1340.
[Abstract]
[Full Text]
[PDF]
|
|
|
Top
Abstract
Introduction
