September 2024 Issue
ISSN 2689-291X
ISSN 2689-291X
Catheter-Induced Coronary Dissection:
Why? And What Next?
Description
The above coronary angiograms from a patient with angina reveal severe proximal left anterior descending (LAD) stenosis in figure A and severe mid right coronary artery (RCA) stenosis in figure B; both amenable to percutaneous coronary intervention (PCI). Balloon inflation and drug-eluting stent deployment to the LAD initially appeared uneventful (figure C); however upon balloon deflation, a major dissection was recognized in the LAD extending into the large first diagonal (figure D), jeopardizing perfusion. Urgent coronary artery bypass grafting was performed successfully using left internal mammary artery to the LAD and saphenous vein grafts to the diagonal and RCA.
Discussion
Catheter-induced coronary artery dissection is uncommon (< 1% of PCIs) but may be underreported and can be detrimental [1]. Certain morphologic features based on the extent of the dissection and degree of flow impairment (table 1) can dictate management and predict clinical outcomes [2].
Several patient-specific, catheter and operator specific factors (table 2) can potentially increase the risk for catheter-induced coronary dissection [3]. Anticipation and preparation helps prevention, in addition to early recognition and management [4].
Management of catheter-induced coronary dissection depends on the anatomy and extent of dissection and compromise of coronary flow [5]. Conservative watchful waiting [6], further endovascular intervention [7], and, as in the above discussed images, cardiac surgery [8] cases have been reported in the literature.
References
The above coronary angiograms from a patient with angina reveal severe proximal left anterior descending (LAD) stenosis in figure A and severe mid right coronary artery (RCA) stenosis in figure B; both amenable to percutaneous coronary intervention (PCI). Balloon inflation and drug-eluting stent deployment to the LAD initially appeared uneventful (figure C); however upon balloon deflation, a major dissection was recognized in the LAD extending into the large first diagonal (figure D), jeopardizing perfusion. Urgent coronary artery bypass grafting was performed successfully using left internal mammary artery to the LAD and saphenous vein grafts to the diagonal and RCA.
Discussion
Catheter-induced coronary artery dissection is uncommon (< 1% of PCIs) but may be underreported and can be detrimental [1]. Certain morphologic features based on the extent of the dissection and degree of flow impairment (table 1) can dictate management and predict clinical outcomes [2].
Several patient-specific, catheter and operator specific factors (table 2) can potentially increase the risk for catheter-induced coronary dissection [3]. Anticipation and preparation helps prevention, in addition to early recognition and management [4].
Management of catheter-induced coronary dissection depends on the anatomy and extent of dissection and compromise of coronary flow [5]. Conservative watchful waiting [6], further endovascular intervention [7], and, as in the above discussed images, cardiac surgery [8] cases have been reported in the literature.
References
- Sosa D 4th, Blankenship JC. The disasters we create: Iatrogenic catheter-induced ostial coronary artery dissection. Catheter Cardiovasc Interv. 2021 Oct;98(4):656-657.
- Huber MS, Mooney JF, Madison J, Mooney MR. Use of a morphologic classification to predict clinical outcome after dissection from coronary angioplasty. Am J Cardiol. 1991 Aug 15;68(5):467-71.
- Boyle AJ, Chan M, Dib J, Resar J. Catheter-induced coronary artery dissection: risk factors, prevention and management. J Invasive Cardiol. 2006 Oct;18(10):500-3.
- Fischman DL, Vishnevsky A. Management of Iatrogenic Coronary Artery Dissections: Failing to Prepare Is Preparing to Fail. JACC Case Rep. 2021 Mar 17;3(3):385-387.
- Page E, Kostantinis S, Karacsonyi J, Allana SS, Walser-Kuntz E, Rangan BV, Simsek B, Rynders B, Mastrodemos OC, Stanberry L, Avula V, Rempakos A, Burke N, Sandoval Y, Mooney M, Sorajja P, Traverse JH, Poulose A, Chavez I, Wang Y, Gössl M, Brilakis ES. Incidence, treatment and outcomes of coronary artery dissection during percutaneous coronary intervention. J Invasive Cardiol. 2023 Jul;35(7):E341-E354.
- Witkowska AM, Perek BO, Olasiñska-Wiœniewska A, Stefaniak S, Jemielity M. Successful conservative management of iatrogenic coronary artery dissection proceeding into the ascending aorta. Kardiochir Torakochirurgia Pol. 2023 Dec;20(4):266-267.
- Hashmani S, Tuzcu E, Hasan F. Successful Bail-Out Stenting for Iatrogenic Right Coronary Artery Dissection in a Young Male. JACC Case Rep. 2019 Aug 21;1(2):108-112.
- Artemiou P, Lukacin S, Kirsch P, Ignac J, Bily B, Tohatyova A, Bilecova-Rabajdova M, Sabol F. Surgical Treatment of a Catheter-Induced Iatrogenic Dissection of the Right Coronary Artery following Cardiac Catheterization. J Tehran Heart Cent. 2016 Jan 13;11(1):30-33.
Table 1. Morphologic Classification of Dissections From Coronary Angioplasty
Table 2. Potential Risk Factors For Catheter-Induced Coronary Dissection
Authors:
Celestine Odigwe, M.D.
Cardiology Fellow
University of South Alabama
Mobile, AL
Brent Ruiz, M.D.
Cardiology Fellow
University of South Alabama
Mobile, AL
Hajira Malik, M.D.
Cardiology Fellow
University of South Alabama
Mobile, AL
Mustafeez Ur Rahman, M.D.
Cardiology Fellow
University of South Alabama
Mobile, AL
Mariam Riad, M.D.
Cardiology Fellow
University of South Alabama
Mobile, AL
Mohammad As Sayaideh, M.D.
Cardiology Fellow
University of South Alabama
Mobile, AL
Sanchitha Nagaraj, M.D.
Cardiology Fellow
University of South Alabama
Mobile, AL
Alexis Parks, D.O.
Cardiology Fellow
University of South Alabama
Mobile, AL
Bassam Omar, M.D., Ph.D.
Professor of Cardiology
University of South Alabama
Mobile, AL
Suganya Manoharan, M.D.
Assistant Professor of Cardiology
University of South Alabama
Mobile, AL
Christopher Malozzi, D.O.
Associate Professor of Cardiology
University of South Alabama
Mobile, AL
Celestine Odigwe, M.D.
Cardiology Fellow
University of South Alabama
Mobile, AL
Brent Ruiz, M.D.
Cardiology Fellow
University of South Alabama
Mobile, AL
Hajira Malik, M.D.
Cardiology Fellow
University of South Alabama
Mobile, AL
Mustafeez Ur Rahman, M.D.
Cardiology Fellow
University of South Alabama
Mobile, AL
Mariam Riad, M.D.
Cardiology Fellow
University of South Alabama
Mobile, AL
Mohammad As Sayaideh, M.D.
Cardiology Fellow
University of South Alabama
Mobile, AL
Sanchitha Nagaraj, M.D.
Cardiology Fellow
University of South Alabama
Mobile, AL
Alexis Parks, D.O.
Cardiology Fellow
University of South Alabama
Mobile, AL
Bassam Omar, M.D., Ph.D.
Professor of Cardiology
University of South Alabama
Mobile, AL
Suganya Manoharan, M.D.
Assistant Professor of Cardiology
University of South Alabama
Mobile, AL
Christopher Malozzi, D.O.
Associate Professor of Cardiology
University of South Alabama
Mobile, AL