Abstract
Iatrogenic aortic dissection during percutaneous coronary intervention is a rare but serious complication. Both conservative and surgical approaches have been proposed as management strategies. We describe a case of an 87-year-old female who presented with an acute coronary syndrome complicated by the development of an ascending aortic dissection during percutaneous intervention, and we provide a brief review of the literature.
Keywords: iatrogenic aortic dissection, percutaneous coronary intervention
Case Presentation
An 87-year-old female patient with a history of hypertension and hyperlipidemia presented to our hospital with acute chest pain. Electrocardiogram showed inferior ST-elevation. Emergent coronary angiogram showed a proximal right coronary artery (RCA) occlusion (Figure 1, online video 1). After successful wiring and angioplasty of the lesion, a stent was deployed to cover the proximal RCA (Figure 2, online video 2). Contrast injection after stent deployment resulted in acute dissection of the right coronary cusp with extension into the proximal ascending aorta (Figure 3, online video 3). A coronary stent was implanted at the ostium to seal the entry site of the dissection. At the end of the procedure, the patient remained stable. Transesophageal echocardiogram showed an ascending aortic intramural hematoma (IMH) (Figure 4). Computed tomography (CT) showed a small aortic intimal tear (Figure 5, white arrow) with an associated IMH (Figure 5, red arrow). Repeat CT scan 4 days later showed no progression of the aortic IMH. The patient was asymptomatic at the 6-week follow-up, with a repeat CT scan showing improvement in the size of the hematoma and resolution of the intimal tear.
Figure 1.
Coronary angiogram showing a proximal right coronary artery (RCA) occlusion. See online video 1.
Figure 2.
Percutanous intervention with stent deployment in the proximal right coronary artery. See online video 2.
Figure 3.
Contrast injection after stent deployment resulting in acute dissection of the right coronary cusp with extension into the proximal ascending aorta. See online video 3.
Figure 4.
Transesophageal echocardiogram showing an ascending aortic intramural hematoma (red arrows).
Figure 5.
Computed tomography (CT) scan showed a small aortic intimal tear (white arrow) with an associated intramural hematoma (red arrow).
Discussion
Iatrogenic coronary artery dissection extending into the coronary sinuses during percutaneous coronary intervention is found in 0.06% to 0.1% of cases.1,2 Iatrogenic retrograde dissection into the ascending aorta during percutaneous coronary intervention is reported in 0.04% of interventional procedures and up to 0.008% of diagnostic coronary angiographies.1,2 Although current literature relating to this complication suggests that surgical management may be indicated, a conservative approach has been adopted in several cases with excellent long-term results.3 Coronary stent implantation can be a therapeutic option since it seals the entry site of the dissection that originates from the coronary ostium.4
Conclusion
We describe a case of percutaneous coronary intervention complicated by the development of an iatrogenic aortic dissection. A conservative strategy with stent implantation has been proposed as a viable alternative to surgical intervention.
Conflict of Interest Disclosure
The authors have completed and submitted the Methodist DeBakey Cardiovascular Journal Conflict of Interest Statement and none were reported.
References
- 1. Yip HK, Wu CJ, Yeh KH, . et al. Unusual complication of retrograde dissection to the coronary sinus of valsalva during percutaneous revascularization: a single-center experience and literature review. Chest. 2001. February; 119( 2): 493– 501. [DOI] [PubMed] [Google Scholar]
- 2. Pérez-Castellano N, García-Fernández MA, García EJ, Delcán JL.. Dissection of the aortic sinus of valsalva complicating coronary catheterization: cause, mechanism, evolution, and management. Cathet Cardiovasc Diagn. 1998. March; 43( 3): 273– 9. [DOI] [PubMed] [Google Scholar]
- 3. Doyle B, Juergens CP. Conservative management of ascending aortic dissection caused by percutaneous coronary intervention. J Invasive Cardiol. 2004. February; 16( 2): 92– 4. [PubMed] [Google Scholar]
- 4. Minicucci F, Galizia G, Ascione L, . et al. Iatrogenic aortic haematoma during primary PTCA: Diagnostic value of transesophageal echocardiography in cath lab. Eur J Echocardiography. 2006. October; 7( 5): 390– 3. [DOI] [PubMed] [Google Scholar]