Catheterization and Cardiovascular Diagnosis 26:8-11 (1992)
Case Reports Aortic Dissection as Complication of Percutaneous Transluminal Coronary Angioplasty Victor P. Moles, MD, Franqois Chappuis, MD, Franqois Sirnonet, MD, Philip Urban, MD, Fernando De La Serna, MD, Abhay K. Pande, MD, and Bernhard Meier, MD We report two cases of aortic dissectlon during coronary angioplasty with a disparate evolution that was due to the different location of the entry port of the dissection. Aortic dissection occurring during coronary angioplasty may be self-limiting, but it may also be life-threatening and may call for urgent surgical repair. IQ1992 Wiiey-Lis, Inc. Key words: diagnostic coronary angiography, therapeutic procedures, recanalization
INTRODUCTION
Coronary artery dissection is a rare complication of diagnostic coronary angiography [ I ] . It is more frequent during percutaneous transluminal coronary angioplasty (PTCA) and other therapeutic procedures [2]. It typically extends down the vessel. However, it may also progress proximally, even (rarely) into the aortic root [3]. We report two cases of coronary dissection extending into the aorta as a complication of coronary angioplasty. CASE REPORTS Case 1 A 48-yr-old man was admitted for coronary angiography because of exertional angina. His exercise test was positive at 120 W. Coronary angiography revealed severe hypokinesia of the anteroseptal wall of the left ventricle and an ejection fraction of 55%. The left anterior descending coronary artery was totally occluded after the first septa1 branch (Fig. 1A). Its distal part was collateralized by the left circumflex and the right coronary artery. The left main coronary artery was normal (Fig. 1A) and the right coronary artery had a proximal moderately severe stenosis. Recanalization of the left anterior descending coronary artery with a 0.021 inch Magnum wire and a 3.0 mm Magnum balloon (Schneider) was attempted. It was impossible to cross the lesion. The Magnum wire was replaced by a 0.014 inch conventional wire to no avail. After a contrast injection through the central lumen of the balloon catheter, an image of dissection of the vessel wall appeared with retrograde extension and dye retention in the left main coronary artery and the aortic root (Fig. 1 B). A contrast medium injection through the guiding catheter revealed a new stenosis at the origin of the left main coronary artery and persistence of contrast meQ 1992 Wiley-Liss, Inc.
dium in the aortic wall (Fig. IC,D). The patient had no chest pain. There were no ECG changes. The procedure was stopped and the patient was transferred to the coronary care unit. He remained stable without ECG changes. He left the hospital under medical treatment and underwent repeat angiography 2 months later, when he was admitted for elective bypass surgery. It showed a normal aspect of the left main coronary artery and the aortic root. The left anterior descending coronary artery remained occluded (Fig. IE). The patient received a sequential internal mammary graft to the left anterior descending coronary artery and the first diagonal branch and a venous graft to the right coronary artery. His recovery was uneventful. Case 2
A 61-yr-old man with recent-onset angina pectoris was admitted for angiographic evaluation. An exercise test was positive at 150 W. Coronary angiography revealed a normal left ventricular function and a subtotal occlusion of the mid-right coronary artery (Fig. 2A), distally collateralized from the left coronary artery. The inferior ventricular wall motion was normal. Recanalization was attempted with a 0.021 inch Magnum wire and a 3.0 mm Magnarail balloon catheter. It was impossible to cross the lesion with the Magnum wire even after deep intubation of the proximal right coronary artery with a 7 French AL 3 Amplatz catheter. The Mag-
From the Cardiology Center, University Hospital, Geneva, Switzerland.
Received August 27. 1991; revision accepted December I . 1991. Address reprint requests to Dr. Rernhard Meier, Cardiology Center, University Hospital, 121 I Geneva 4 , Switzerland.
Aortic Dissection: Complication of PTCA
9
Fig. 1. A: Total occlusion of the left anterior descending coronary artery (arrow) with collaterals from their left circumflex coronary artery (small arrow). 8 : Dye retention in the wall of the proximal left anterior descending coronary artery (arrow) and the aortlc root (small arrow) after contrast medium injection through the balloon catheter. C: Contrast medium Injection through the guiding catheter showing a new stenosis of the origin of left main coronary artery created by an annular deposit of contrast medium (arrows). Persistence of the contrast medium in the wall of the left anterlor descending coronary artery (small arrow). D: Contrast medium retention in the arotic root (arrows). E: Angiography 2 months later showing a normal aspect of the left main stem and persistence of the proximal left anterior descending coronary artery occlusion.
10
Moles et al.
Fig. 2. A: Subtotal occlusion of the right coronary artery (arrow). B: Dye retention in the arotic wall, sinus of Valsalva, and proximal right coronary artery after contrast injection through an 8 French Amplatz guiding catheter. The tip of the catheter is in the right coronary artery (arrow). Proximal dissection of the right coronary artery (small arrow) not communicating with the aortic dissection. C: Aortic angiogram in a right
anterior oblique projection revealing persistence of contrast medium in the aortic wall (arrow). D: Repeat aortic angiography the following day in a left anterior oblique projection showing an intimal flap in the entire aorta (arrows). The left ventricle is opacified because of severe aortic regurgitation by a distorted leaflet.
num wire was replaced by a 0.014 inch wire (Schneider) and then by a 0.014 inch standard wire (ACS). The guiding catheter was replaced by an 8 F AL2 Amplatz catheter. After placement of the new guinding catheter in what was presumed to be the origin of the right coronary
artery and an injection of contrast medium, a dissection image with dye retention appeared, involving the sinus of Valsalva and the aortic root (Fig. 2B). The patient developed chest pain. Aortic angiography revealed a tlissection of the ascending aorta and dye retention in the
Aortic Dissection: Complication of PTCA
aortic wall (Fig. 2C). There was only trivial aortic regurgitation. The patient was transferred to the intensive care unit. He remained hemodynamically stable but the pain persisted. A new diastolic murmur was heard and an echocardiogram revealed aortic regurgitation with a small pericardial effusion. Repeat aortic angiography the next day revealed a dissection of the ascending aorta extending distally beyond the iliac bifurcation, and severe aortic regurgitation (Fig. 2D). At surgery, performed the same day, a small conal coronary artery originating 1 cm above the right coronary artery was found. I had a 2 mm laceration communicating with the false lumen of the aortic dissection. The dissection was repaired by interposing a Dacron tube of about 3 cm, which corrected the incompetence of the aortic valve. The right coronary artery was bypassed. The patient was discharged 6 days later. DISCUSSION
Aorto-coronary dissection complicating coronary angiography has been previously reported [3]. To our knowledge, this is the first report of aortic dissection as a complication of coronary angioplasty. The two cases reported had a different etiology and evolution. In both cases, the dissecting agent was the contrast medium injected into the subintimal space. In the first case, the injection was performed through the large lumen of the Magnum balloon catheter equiped with only a 0.014 inch wire and in the second case through an 8 F guiding catheter. Although only small quantities were injected (about 1 ml), the contrast medium dispersed over a significant area following the path of least resistance, i.e., the space between media and adventitia. In the first case, the entry port was in the mid-left anterior descending coronary artery. It was protected from blood inflow by the occlusion of the vessel. The dissection of the aorta was limited to the segment adjacent to the coronary ostium, and resolved spontaneously as the causing agent (contrast medium) was absorbed. The left main stenosis was considered of minor concern since it was produced by a subintimal cushion of contrast medium (Fig. IC) bound to disappear spontaneously. This was confirmed by the subsequent clinical course and follow-up angiography. In the second case, the dissection started at the origin of a conal artery with a separate ostium. The entry port was exposed to the aortic blood stream, which lent
11
to the subsequent extension of the dissection. The contrast medium in the right coronary cusp dislodged the aortic leaflet producing aortic insufficiency. This was not immediately recognized because the initial aortic angiogram was performed with the catheter in the false lumen thereby poorly revealing the extent of the aortic insufficiency. At repeat aortic angiography prompted by a color Doppler echocardiogram showing marked aortic regurgitation, the catheter happened to be in the true lumen, revealing the problem more accurately. The small laceration found at surgery may have been the result of manipulations with the rigid guidewire used last or too vigorous a contrast medium injection with the guiding catheter wedged in the small ostium. The different courses of these two cases are primarily related to the different entry ports. Both entry ports were created by mechanical trauma and/or forceful injection of contrast medium into the subintimal space. Whether medial degeneration of the respective arteries [4-61 played a role cannot be determined because there is no histology in either case. Aortic dissection during coronary angioplasty may occur secondary to contrast injection into the subintimal layers. It may be self-limiting, but it may also be a lifethreatening event calling for urgent surgery. In case of contrast medium retention in the aortic wall, an aortogram should be carried out complemented by a Doppler echocardiogram, an even better screening method for aortic dissection and aortic regurgitation.
REFERENCES I . Bourassa MG. Noble J : Complication rate of coronary arteriography. A review of 5250 cases studied by a percutaneous femoral technique. Circulation 53: 106-1 14. 1976. 2. Roew MH. Hinohara T, White NW, Robertson GC, Selmon MR. Simpson JB: Comparison of dissection rates and angiographic results following directional coronary atherectomy and coronary angioplasty. Am J Cardiol 66:49-53, 1990. 3. Geraci AR, Krishnaswami V, Selman MW: Aorto-coronary dissection complicating coronary arteriography. J Thorac Cardiovasc Surg 65695-698, 1973. 4. Bulkley BH, Roberts WC: Dissecting aneurysms (hematoma) limited to coronary artery. Am J Med 55747-756, 1973. 5. Morise AP. Hardin NJ, Bovil EG, Gundel WD: Coronary artery dissection secondary to coronary arteriography. Cathet Cardiovasc Diagn 7:283-296, 1981. 6 . Schlatmann TJM, Becker AE: Pathogenesis of dissecting aneurysms of the aorta. Am J Cardiol 39:22-26, 1976.
Case Reports Aortic Dissection as Complication of Percutaneous Transluminal Coronary Angioplasty Victor P. Moles, MD, Franqois Chappuis, MD, Franqois Sirnonet, MD, Philip Urban, MD, Fernando De La Serna, MD, Abhay K. Pande, MD, and Bernhard Meier, MD We report two cases of aortic dissectlon during coronary angioplasty with a disparate evolution that was due to the different location of the entry port of the dissection. Aortic dissection occurring during coronary angioplasty may be self-limiting, but it may also be life-threatening and may call for urgent surgical repair. IQ1992 Wiiey-Lis, Inc. Key words: diagnostic coronary angiography, therapeutic procedures, recanalization
INTRODUCTION
Coronary artery dissection is a rare complication of diagnostic coronary angiography [ I ] . It is more frequent during percutaneous transluminal coronary angioplasty (PTCA) and other therapeutic procedures [2]. It typically extends down the vessel. However, it may also progress proximally, even (rarely) into the aortic root [3]. We report two cases of coronary dissection extending into the aorta as a complication of coronary angioplasty. CASE REPORTS Case 1 A 48-yr-old man was admitted for coronary angiography because of exertional angina. His exercise test was positive at 120 W. Coronary angiography revealed severe hypokinesia of the anteroseptal wall of the left ventricle and an ejection fraction of 55%. The left anterior descending coronary artery was totally occluded after the first septa1 branch (Fig. 1A). Its distal part was collateralized by the left circumflex and the right coronary artery. The left main coronary artery was normal (Fig. 1A) and the right coronary artery had a proximal moderately severe stenosis. Recanalization of the left anterior descending coronary artery with a 0.021 inch Magnum wire and a 3.0 mm Magnum balloon (Schneider) was attempted. It was impossible to cross the lesion. The Magnum wire was replaced by a 0.014 inch conventional wire to no avail. After a contrast injection through the central lumen of the balloon catheter, an image of dissection of the vessel wall appeared with retrograde extension and dye retention in the left main coronary artery and the aortic root (Fig. 1 B). A contrast medium injection through the guiding catheter revealed a new stenosis at the origin of the left main coronary artery and persistence of contrast meQ 1992 Wiley-Liss, Inc.
dium in the aortic wall (Fig. IC,D). The patient had no chest pain. There were no ECG changes. The procedure was stopped and the patient was transferred to the coronary care unit. He remained stable without ECG changes. He left the hospital under medical treatment and underwent repeat angiography 2 months later, when he was admitted for elective bypass surgery. It showed a normal aspect of the left main coronary artery and the aortic root. The left anterior descending coronary artery remained occluded (Fig. IE). The patient received a sequential internal mammary graft to the left anterior descending coronary artery and the first diagonal branch and a venous graft to the right coronary artery. His recovery was uneventful. Case 2
A 61-yr-old man with recent-onset angina pectoris was admitted for angiographic evaluation. An exercise test was positive at 150 W. Coronary angiography revealed a normal left ventricular function and a subtotal occlusion of the mid-right coronary artery (Fig. 2A), distally collateralized from the left coronary artery. The inferior ventricular wall motion was normal. Recanalization was attempted with a 0.021 inch Magnum wire and a 3.0 mm Magnarail balloon catheter. It was impossible to cross the lesion with the Magnum wire even after deep intubation of the proximal right coronary artery with a 7 French AL 3 Amplatz catheter. The Mag-
From the Cardiology Center, University Hospital, Geneva, Switzerland.
Received August 27. 1991; revision accepted December I . 1991. Address reprint requests to Dr. Rernhard Meier, Cardiology Center, University Hospital, 121 I Geneva 4 , Switzerland.
Aortic Dissection: Complication of PTCA
9
Fig. 1. A: Total occlusion of the left anterior descending coronary artery (arrow) with collaterals from their left circumflex coronary artery (small arrow). 8 : Dye retention in the wall of the proximal left anterior descending coronary artery (arrow) and the aortlc root (small arrow) after contrast medium injection through the balloon catheter. C: Contrast medium Injection through the guiding catheter showing a new stenosis of the origin of left main coronary artery created by an annular deposit of contrast medium (arrows). Persistence of the contrast medium in the wall of the left anterlor descending coronary artery (small arrow). D: Contrast medium retention in the arotic root (arrows). E: Angiography 2 months later showing a normal aspect of the left main stem and persistence of the proximal left anterior descending coronary artery occlusion.
10
Moles et al.
Fig. 2. A: Subtotal occlusion of the right coronary artery (arrow). B: Dye retention in the arotic wall, sinus of Valsalva, and proximal right coronary artery after contrast injection through an 8 French Amplatz guiding catheter. The tip of the catheter is in the right coronary artery (arrow). Proximal dissection of the right coronary artery (small arrow) not communicating with the aortic dissection. C: Aortic angiogram in a right
anterior oblique projection revealing persistence of contrast medium in the aortic wall (arrow). D: Repeat aortic angiography the following day in a left anterior oblique projection showing an intimal flap in the entire aorta (arrows). The left ventricle is opacified because of severe aortic regurgitation by a distorted leaflet.
num wire was replaced by a 0.014 inch wire (Schneider) and then by a 0.014 inch standard wire (ACS). The guiding catheter was replaced by an 8 F AL2 Amplatz catheter. After placement of the new guinding catheter in what was presumed to be the origin of the right coronary
artery and an injection of contrast medium, a dissection image with dye retention appeared, involving the sinus of Valsalva and the aortic root (Fig. 2B). The patient developed chest pain. Aortic angiography revealed a tlissection of the ascending aorta and dye retention in the
Aortic Dissection: Complication of PTCA
aortic wall (Fig. 2C). There was only trivial aortic regurgitation. The patient was transferred to the intensive care unit. He remained hemodynamically stable but the pain persisted. A new diastolic murmur was heard and an echocardiogram revealed aortic regurgitation with a small pericardial effusion. Repeat aortic angiography the next day revealed a dissection of the ascending aorta extending distally beyond the iliac bifurcation, and severe aortic regurgitation (Fig. 2D). At surgery, performed the same day, a small conal coronary artery originating 1 cm above the right coronary artery was found. I had a 2 mm laceration communicating with the false lumen of the aortic dissection. The dissection was repaired by interposing a Dacron tube of about 3 cm, which corrected the incompetence of the aortic valve. The right coronary artery was bypassed. The patient was discharged 6 days later. DISCUSSION
Aorto-coronary dissection complicating coronary angiography has been previously reported [3]. To our knowledge, this is the first report of aortic dissection as a complication of coronary angioplasty. The two cases reported had a different etiology and evolution. In both cases, the dissecting agent was the contrast medium injected into the subintimal space. In the first case, the injection was performed through the large lumen of the Magnum balloon catheter equiped with only a 0.014 inch wire and in the second case through an 8 F guiding catheter. Although only small quantities were injected (about 1 ml), the contrast medium dispersed over a significant area following the path of least resistance, i.e., the space between media and adventitia. In the first case, the entry port was in the mid-left anterior descending coronary artery. It was protected from blood inflow by the occlusion of the vessel. The dissection of the aorta was limited to the segment adjacent to the coronary ostium, and resolved spontaneously as the causing agent (contrast medium) was absorbed. The left main stenosis was considered of minor concern since it was produced by a subintimal cushion of contrast medium (Fig. IC) bound to disappear spontaneously. This was confirmed by the subsequent clinical course and follow-up angiography. In the second case, the dissection started at the origin of a conal artery with a separate ostium. The entry port was exposed to the aortic blood stream, which lent
11
to the subsequent extension of the dissection. The contrast medium in the right coronary cusp dislodged the aortic leaflet producing aortic insufficiency. This was not immediately recognized because the initial aortic angiogram was performed with the catheter in the false lumen thereby poorly revealing the extent of the aortic insufficiency. At repeat aortic angiography prompted by a color Doppler echocardiogram showing marked aortic regurgitation, the catheter happened to be in the true lumen, revealing the problem more accurately. The small laceration found at surgery may have been the result of manipulations with the rigid guidewire used last or too vigorous a contrast medium injection with the guiding catheter wedged in the small ostium. The different courses of these two cases are primarily related to the different entry ports. Both entry ports were created by mechanical trauma and/or forceful injection of contrast medium into the subintimal space. Whether medial degeneration of the respective arteries [4-61 played a role cannot be determined because there is no histology in either case. Aortic dissection during coronary angioplasty may occur secondary to contrast injection into the subintimal layers. It may be self-limiting, but it may also be a lifethreatening event calling for urgent surgery. In case of contrast medium retention in the aortic wall, an aortogram should be carried out complemented by a Doppler echocardiogram, an even better screening method for aortic dissection and aortic regurgitation.
REFERENCES I . Bourassa MG. Noble J : Complication rate of coronary arteriography. A review of 5250 cases studied by a percutaneous femoral technique. Circulation 53: 106-1 14. 1976. 2. Roew MH. Hinohara T, White NW, Robertson GC, Selmon MR. Simpson JB: Comparison of dissection rates and angiographic results following directional coronary atherectomy and coronary angioplasty. Am J Cardiol 66:49-53, 1990. 3. Geraci AR, Krishnaswami V, Selman MW: Aorto-coronary dissection complicating coronary arteriography. J Thorac Cardiovasc Surg 65695-698, 1973. 4. Bulkley BH, Roberts WC: Dissecting aneurysms (hematoma) limited to coronary artery. Am J Med 55747-756, 1973. 5. Morise AP. Hardin NJ, Bovil EG, Gundel WD: Coronary artery dissection secondary to coronary arteriography. Cathet Cardiovasc Diagn 7:283-296, 1981. 6 . Schlatmann TJM, Becker AE: Pathogenesis of dissecting aneurysms of the aorta. Am J Cardiol 39:22-26, 1976.
