Ann Thorac Surg 2002;74:1248-1250
© 2002 The Society of Thoracic Surgeons
Case report
Extensive coronary dissection treated with endarterectomy and coronary reconstruction
W. Dudley Johnson, MD*a,
Tanvir K. Bajwa, MDa,
Suhail Q. Allaqaband, MDa,
Mary R. Howard, RNa
a Department of Cardiothoracic Surgery and Cardiology, Sinai Samaritan Hospital, Milwaukee, Wisconsin, USA
* Address reprint requests to Dr Johnson, 350 Bishops Way, Suite 202, Brookfield, WI 53005 USA
e-mail: life{at}wdudleyjohnson.com
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Abstract
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Acute coronary dissection is an uncommon event, usually not related to typical coronary risk factors, usually in women, and usually diagnosed at autopsy. This report describes a young woman with extensive left anterior descending coronary artery (LAD) dissection, refused for intervention since there was no lesion to angioplasty and no artery to bypass. A long arteriotomy was made, removing under direct vision all of the torn and dissected tissue, just as would be done for extensive LAD endarterectomy. A vein was split and attached to reconstruct the artery. Normal left ventricular function was restored.
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Introduction
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Spontaneous coronary artery dissection (SCAD) remains a rare cause of myocardial ischemia. First described by Pretty in 1931, more than 200 cases have been reported in the literature, and most were diagnosed at necropsy. This is a rare report of successful coronary reconstruction after extensive dissection occurred.
We report a 39-year-old woman who presented to the emergency department with severe chest pain radiating to both arms. Over 2 weeks, the pain had progressed from exertional only to severe rest pain. She had no other medical problems and no coronary risk factors. Admission tests indicated anterior wall ischemia. An urgent catheterization revealed severe left anterior descending coronary artery (LAD) disease involving the mid-to-distal artery (Fig 1).
The left ventricular ejection fraction was calculated to be 50%.
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Fig 1. Initial catheterization revealed severe left anterior descending coronary artery disease involving the mid-to-distal artery (arrow).
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Because of the long area of stenosis and small distal artery, angioplasty and bypass procedures were rejected by the attending cardiologist and surgeon. She was therefore transferred to our hospital to undergo coronary artery bypass grafting with probable coronary endarterectomy.
During surgery, there was no evidence of atherosclerotic coronary artery disease. The LAD was blue-purple with the appearance of a thrombosed vessel. The LAD was opened near the apex, and only a trace of blood flow appeared. The arteriotomy was extended several centimeters proximally where the artery was normal in appearance with brisk flow. Fragments of dissected intima and blood clot were present throughout the involved artery. A large linear tear was noted posteriorly near the origin of the dissection. All intima and clot were removed in the involved segment. A saphenous vein was split and attached over the entire length of the 8-cm arteriotomy to reconstruct the LAD. Proximally, the vein was anastomosed to the aorta. As with all endarterectomy patients, long-term aspirin was ordered, and a life-long antithrombotic, antiatherosclerotic, Omega 3 diet prescribed. Low molecular heparin for pulmonary embolus prophylaxis was used for several days.
Cardiac catheterization performed on the 5th postoperative day showed a widely patent LAD with TIMI III flow visible in the septal and diagonal branches (Fig 2).
The left ventricular ejection fraction improved from 50% to 75%. Hematological studies were normal. Microscopic examination showed a partially organized blood clot with no evidence of atherosclerotic material, medial necrosis, nor vasculitis. Gram staining, kinyoun staining, periodic acid-schiff stain, and elastic stain were all negative.
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Fig 2. Catheterization postoperatively showed a widely patent left anterior descending coronary artery (thick arrow) with TIMI III flow visible in the septal and diagonal branches (thin arrows).
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The postoperative course was uneventful and the patient was discharged to home on the 6th postoperative day. The patient continues to be chest pain-free at 1 year.
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Comment
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SCAD has been defined as an intramural hematoma that occurs between the adventitial layer and the media of the vessel wall, occluding the true lumen [1]. SCAD has been associated with exercise, oral contraceptives, Ehlers-Danlos syndrome, cocaine use, postpartum period or late pregnancy, atherosclerosis, and an idiopathic group with no risk factors for coronary artery disease.
Clinically, SCAD can be present in a variety of ways ranging from stable angina, to acute myocardial infarction, to sudden cardiac death. Females are more commonly affected (75% to 80% of all cases). SCAD usually occurs as a single-vessel LAD disease, especially in women [2]. In men, the right coronary artery is involved in two-thirds of the cases.
Angiography is diagnostic if two lumina are separated by an intimal flap. Dissection may be unclear on angiography, as was the case in our patient.
Optimal treatment for SCAD has not been defined. Medical therapy alone has good results in some patients, usually with short dissection. Zampieri and colleagues [1] reported on a series of 5 patients treated with only aspirin, nitrates, and beta-blockers. After a mean follow-up of 25 months, 4 patients had no evidence of recurrence of ischemia. Jorgensen and associates [2] described successful medical management in 7 out of 10 cases; however, 3 patients required coronary artery bypass grafting. Successful thrombolytic therapy for acute myocardial infarction due to SCAD has also been reported [3, 4]. However, there have also been cases of the extension of dissection after administration of thrombolytics [4]. More recently, glycoprotein IIB/IIIA inhibitors have been used to promote spontaneous healing of SCAD [5].
Nonsurgical revascularization with percutaneous transluminal coronary angioplasty and, more recently, intracoronary stenting has been reported [6]. Forker and coworkers, in 1973, performed bilateral internal artery implantation [7]. Subsequently, a number of cases of coronary artery bypass grafting for SCAD have been reported [8–10].
Our patient is a rare case of long, extensive coronary dissection, unsuitable for bypass or angioplasty in which endarterectomy and reconstruction was accomplished. Removing the entire torn intima and reconstructing the dissected artery with a saphenous vein graft is easier and safer than attempting to repair the damaged vessel. The intima is not needed for coronary function. Extensively damaged intima should be removed, and the artery reconstructed as described.
Although rare, SCAD should be suspected in young patients who have a low likelihood of having atherosclerotic coronary artery disease and present with acute coronary syndrome. Multiple conventional methods have been used to handle localized dissections. This case illustrates successful management of a long dissection with endarterectomy and coronary reconstruction.
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References
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- Zampieri P., Aggio S., Roncon L., et al. Follow-up after spontaneous coronary artery dissection: a report of 5 cases. Heart 1996;75:206-209.[Abstract/Free Full Text]
- Jorgensen M.B., Aharonian V., Mansukhani P., Mahrer P.R. Spontaneous coronary dissection: a cluster of cases with this rare finding. Am Heart J 1994;127:1382-1387.[Medline]
- Leclercq F., Messner-Pellenc P., Carabasse D., Lucke N., Rivalland F., Grolleau R. Successful thrombolysis treatment of a spontaneous left main coronary artery dissection without subsequent surgery. Eur Heart J 1996;17:320-321.[Free Full Text]
- Buys E.M., Suttorp M.J., Morshuis W.J., Plokker H.W. Extension of a spontaneous coronary artery dissection due to thrombolytic therapy. Cathet Cardiovasc Diagn 1994;33:157-160.[Medline]
- Cheung S., Mithani V., Watson R.M. Healing of spontaneous coronary dissection in the context of glycoprotein IIB/IIIA inhibitor therapy: a case report. Catheter Cardiovasc Intervent 2000;51:95-100.[Medline]
- Vale P.R., Baron D.W. Coronary artery stenting for spontaneous coronary artery dissection: a case report and review of the literature. Cathet Cardiovasc Diagn 1998;42:280-286.
- Forker A.D., Rosenlof R.C., Weaver W.F., Carveth S.W., Reese H.E. Primary dissecting aneurysm of the right coronary artery with survival. Chest 1973;64:656-658.[Abstract/Free Full Text]
- Thayer J.O., Healy R.W., Maggs P.E. Spontaneous coronary artery dissection. Ann Thorac Surg 1987;44:97-107.[Abstract]
- Boyd W.D. Surgical treatment of spontaneous left main coronary artery dissection. Ann Thorac Surg 1998;46:483.
- Atay Y., Yagdi T., Turkoglu C., Altintig A., Buket S. Spontaneous dissection of the left main coronary artery: a case report and review of the literature. J Cardiovasc Surg 1996;11:371-375.
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Abstract
Introduction
