Successful Percutaneous Management of Iatrogenic Left Main Coronary Artery and Ascending Aorta Dissection.

Iatrogenic left main coronary artery and aortic root dissection is a rare but life-threatening complication of percutaneous coronary intervention. This is a case where this complication was induced by catheter manipulation. Prompt percutaneous closure of the dissection point of entry was effective in managing this complication. (Level of Difficulty: Advanced.).

A 62-year-old man was admitted to the emergency department with unstable angina. Physical examination revealed a blood pressure of 124/73 mm Hg, heart rate of 89 beats/min, and no signs of poor peripheral perfusion or congestion. Electrocardiogram, transthoracic echocardiography, and troponin levels were unremarkable. His medical history included a non-ST-segment elevation myocardial infarction 2 years previously with right coronary artery (RCA) and left anterior descending artery (LAD) percutaneous coronary intervention (PCI). Coronary angiography revealed good result intrastent in the RCA and intrabioresorbable scaffolding in the LAD; this examination showed de novo critical stenosis of the ostial first obtuse marginal artery (OM) and intermediate stenosis of the proximal circumflex artery (CX) (Figure 1A). The first was assumed to be the culprit lesion, and PCI was performed with direct implantation of an everolimus-eluting stent in the CX/OM axis (Video 1). At the end, some resistance was found when the jailed guidewire was removed from the distal CX (Figure 1B). After removal of all of the guidewires, coronary angiography revealed severe left main coronary artery (LM) dissection with anterograde extension, causing LAD/CX occlusion and a retrograde dissection toward the aortic root and the ascending aorta (Figures 1C to 1E, Supplemental Video 2, Supplemental Video 3). An immediate bailout culotte stenting strategy of the LM/LAD/CX system was performed to close the point of entry of the dissection and to contain the progression of the lesion (Figure 1F, Supplemental Video 4, Supplemental Video 5). Emergent transthoracic echocardiography did not show any complications such as aortic regurgitation or pericardial effusion. Emergent thoracic computed tomography (CT) (Figure 1G, Video 6) did not identify any signs of aortic dissection despite the angiographic appearance lending support to a conservative approach in the treatment of the patient. as discussed with the heart team. The patient was admitted to the cardiac intensive care unit and remained asymptomatic and in a hemodynamically stable condition. CT after 24 hours remained unremarkable, without evidence of aortic dissection by this technique (Figure 1H, Video 7). Surgical intervention was deferred, and the patient was discharged on day 4. After 1 year of follow-up, the patient remained asymptomatic, and CT was normal.

Figure 1

Coronary Angiography, Percutaneous Coronary Intervention of the First Obtuse Marginal Artery, Diagnosis of Iatrogenic Left Main Coronary Artery Dissection With Retrograde Extension into the Aortic Root and Bailout Stenting

(A) Coronary angiography of the left system showing critical stenosis of the first obtuse marginal artery (white arrow). (B) Some resistance was found when removing the jailed guidewire from the distal circumflex artery (CX); note the deeper and more angulated left main coronary artery (LM) engagement after wire pullback (yellow arrow). (C, D) Coronary angiography after removal of guidewires, revealing LM dissection (white arrowheads) with compromised left anterior descending artery and CX distal flow, associated with retrograde extension into the aortic root; note the angulated position of the guiding catheter (red arrow). (E) Increased extension of aortic dissection (yellow arrowheads). (F) Final result after bailout stenting. (G, H) Computed tomography angiography emergent and 24 hours after LM dissection without evidence of aortic dissection or pericardial effusion (slice immediately above the level of the LM ostium; ascending aorta is identified by yellow arrow).

Iatrogenic aortocoronary dissection is a rare but life-threatening event and one of the most dreaded complications of PCI, with a reported incidence of 0.12%. Extensive catheter manipulation, catheter curve, stiffer guidewires, unusual coronary anatomy or location, and presence of atherosclerosis have all been associated with an increased risk of dissection. It is more frequent in catheterization of the RCA than of the LM because of the differences in anatomy and histologic structures. Currently, there are no clear guidelines for the management of this complication. Some algorithms have been proposed., They are based in the patient’s clinical stability, the coronary flow in the dissected artery, and the aortic involvement as well as its extension. In consideration of the high risk of surgical treatment, patients should be carefully selected. In fact, there are reports of patients whose dissections extended even to the aortic arch and have been successfully treated conservatively or nonsurgically by means of bailout stenting.

Our case reinforces that bailout stenting can be an effective strategy for immediate closure of the dissection point of entry, preventing it from expanding and inducing severe clinical deterioration even in cases of aortic involvement.

Funding Support and Author Disclosures

The authors have reported that they have no relationships relevant to the contents of this paper to disclose.