Canadian Journal of Cardiology 31 (2015) 320e327
Clinical Research
Iatrogenic Aortic Dissection Complicating Percutaneous Coronary Intervention for Chronic Total Occlusion Marouane Boukhris, MD,a,b Salvatore Davide Tomasello, MD,a Francesco Marzà, MD,a Salvatore Azzarelli, MD,a and Alfredo Ruggero Galassi, MD, FACC, FESC, FSCAIa a
Department of Medical Sciences and Pediatrics, Catheterization Laboratory and Cardiovascular Interventional Unit, Division of Cardiology, Cannizzaro Hospital, University of Catania, Catania, Italy b
Faculty of Medicine of Tunis, University Tunis El Manar, Tunis, Tunisia
ABSTRACT
RESUM E
Background: We aimed to determine the prevalence of iatrogenic aortic dissection in chronic total occlusion (CTO) recanalization procedures, and to assess the management strategy and outcome of such a complication. Methods: This study was a retrospective analysis of CTO percutaneous coronary intervention (PCI) cases performed by a single CTO experienced operator. Iatrogenic aortic dissection was defined as persistent contrast staining in the aortic cusp or root. Results: Among 956 CTO PCI cases, iatrogenic aortic dissection occurred in 8 patients for an overall frequency of 0.83%. The right coronary artery was the CTO involved vessel in all cases with ostial location and severe calcifications in 37.5% and 62.5% of cases, respectively. Four patients underwent the antegrade approach and a retrograde strategy was adopted in the remaining 4 patients. The iatrogenic aortic dissection started from the right sinus of Valsalva in 87.5% of cases and catheter trauma was the presumed mechanism of dissection in most cases. Stenting of the entry point was performed in all cases, and dissection was limited (< 40 mm) in all patients. No patients required emergency surgery. One cardiac death was observed 12 days after the index procedure (12.5%), and a mean follow-up of 31.5 months was uneventful in the remaining 7 patients.
tait de de terminer la pre valence de la Introduction : Notre but e dissection iatrogène de l’aorte lors des interventions de recanalisation valuer la strate gie de d’une occlusion totale chronique (OTC) et d’e sultats de cette complication. prise en charge et les re thodes : L’e tude dont il est question ici e tait une analyse Me trospective des cas d’interventions coronariennes percutane es (ICP) re alise es par un seul ope rateur expe rimente dans les d’OTC. La d’OTC re tait de finie comme une coloration de dissection iatrogène de l’aorte e contraste persistante de la cuspide ou de la racine aortiques. sultats : Parmi les 956 cas d’ICP d’OTC, la dissection iatrogène de Re quence globale de 0,83 %. l’aorte survenait chez 8 patients selon une fre tait le vaisseau touche par l’OTC dans tous L’artère coronaire droite e s à l’ostium et ayant des calcifications graves, soit dans les cas situe 37,5 % et 62,5 % des cas, respectivement. Quatre patients subissaient rograde, puis les 4 patients restants sul’approche par voie ante trograde. La dissection iatrogène de bissaient une approche par voie re l’aorte partait du sinus de Valsalva droit dans 87,5 % des cas et le ter e tait le me canisme pre sume de la dissectraumatisme par cathe tion dans la plupart des cas. L’implantation de l’endoprothèse au point e e tait re alise e dans tous les cas, et la dissection e tait limite e d’entre (< 40 mm) chez tous les patients. Aucun patient n’avait besoin d’une
It is well demonstrated that successful revascularization of chronic total occlusion (CTO) improves left ventricular function,1 increased myocardial perfusion,2,3 reduced left ventricular remodelling,4 and increased electrical stability.5 However, despite the development of techniques and equipment6-8 with high success rates (75%-90%) achieved by
experienced operators,9,10 percutaneous coronary intervention (PCI) in CTO lesions remains associated with a greater incidence of procedural complications compared with nonCTO PCI.11,12 Dissection of the ascending aorta is a very rare iatrogenic complication of PCI with an incidence of 0.03%-0.06%.13 The trigger of such a complication is a dissection of the coronary sinus of Valsalva, which progressively extends to the ascending aorta. The appropriate therapeutic strategy is still controversial. The aim of this study was to determine the prevalence of aortic dissection occurring in CTO revascularization procedures and to assess the management strategy and the outcome of such a complication.
Received for publication October 1, 2014. Accepted November 30, 2014. Corresponding author: Dr Alfredo Ruggero Galassi, Via Antonello da Messina 75, Acicastello, 95021 Catania, Italy. Tel.: þ39-095-7263122-3623; fax: þ39-095-7263124-3633. E-mail: [email protected] See page 326 for disclosure information.
http://dx.doi.org/10.1016/j.cjca.2014.11.030 0828-282X/Ó 2015 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.
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Conclusions: CTO recanalization procedures might be associated with a greater incidence of iatrogenic aortic dissection than non-CTO PCI. The therapeutic strategy and outcome depend on the rapidity of the entry point sealing and the degree of extension of the dissection into the aorta in serial imaging assessment.
tait observe e 12 jours après chirurgie d’urgence. Une mort cardiaque e fe rence (12,5 %), et un suivi moyen de 31,5 mois l’intervention de re tait de roule sans incident chez les 7 patients restants. s’e Conclusions : Les interventions de recanalisation d’OTC seraient es à une plus grande fre quence de dissection iatrogène de associe gie the rapeutique et les l’aorte que les non-ICP d’OTC. La strate sultats de pendent de la rapidite de la fermeture du point d’entre e et re d’extension de la dissection de l’aorte à l’e valuation de du degre rielle. l’imagerie se
Methods
administered if patients were not pretreated. The choice of the guiding catheter, the CTO recanalization approach, the use of CTO devices, and the choice of aortic dissection treatment were completely based on the operator’s discretion and experience.
Study population This study was a retrospective analysis of CTO PCI cases performed by a single CTO experienced operator, from January 2006 to April 2014. Iatrogenic aortic dissection was defined as persistent contrast staining in the aortic cusp or root. Definitions CTO was defined as a coronary obstruction with Thrombolysis in Myocardial Infarction (TIMI) flow grade 0 with an estimated duration > 3 months.14 The indication for the percutaneous treatment of CTO was based on the demonstration of viable myocardium in the territory of the occluded vessel using echographic or scintigraphic provocative tests, whereas no CTO angiographic characteristic was considered as an absolute contraindication to attempt PCI. Angiographic success was defined as a residual stenosis < 30% with a final TIMI flow grade 3 at the end of the procedure. Two experienced interventional cardiologists evaluated together the cine films of patients who experienced iatrogenic aortic dissection, as a consequence of the CTO recanalization procedure; and a cardiologist involved in cardiovascular imaging reviewed their echocardiograms and computed tomography (CT) angiograms. The Dunning classification15 was used to describe the extension of aortic dissection: class 1 was defined as a focal dissection restricted to the coronary cusp; in class 2 the dissection extended up the ascending aorta but < 40 mm; and class 3 included dissections extending from the coronary cusp up to the ascending aorta > 40 mm. Major adverse cardiac and cerebral events were defined as cardiac death, acute myocardial infarction, stroke, or further revascularization. Procedure All procedures were scheduled, and all patients were pretreated with 100 mg of aspirin daily. At the beginning of the procedure, patients received intravenous unfractionated heparin (80-100 IU/kg) to maintain activated clotting time > 300 seconds, and activated clotting time was monitored every 30 minutes to determine if an additional bolus of unfractionated heparin was necessary. No patients were treated with glycoprotein IIb/IIIa inhibitors or bivalirudin. A 600-mg loading dose of clopidogrel before the procedure was
Statistical analysis Continuous variables were presented as mean and ranges. Categorical variables were presented as counts and percentages. All data were processed using the Statistical Package for Social Sciences, version 21 (SPSS, Chicago, IL). Results Prevalence of iatrogenic aortic dissection and characteristics Among 956 patients with at least 1 CTO lesion, treated by a single CTO dedicated experienced operator, iatrogenic aortic dissection was diagnosed in 8 patients for an overall frequency of 0.83%. The mean age was 63.5 years (range, 53-71 years) and 6 patients (75%) were male. Four patients (50%) were diabetic; hypertension and dyslipidemia were observed in 87.5% and 62.5% of cases, respectively; and 5 patients (62.5%) were current smokers. A history of myocardial infarction was noticed in 3 patients (37.5%), and all patients underwent previous revascularization: previous PCI in 4 cases (50%), and previous coronary artery bypass in 4 cases (50%). The clinical presentation was stable angina in all patients: Canadian Cardiovascular Society class 2 in 7 patients (87.5%), and Canadian Cardiovascular Society class 3 in the remaining patient (12.5%). The mean left ventricular ejection fraction was 52.5% (range, 45%-55%). All patients had multivessel disease with 1 CTO lesion, and the right coronary artery (RCA) was the target vessel in all cases. An ostial CTO location was observed in 3 cases (37.5%); severe calcification in 5 cases (62.5%); and 5 patients (62.5%) had a CTO length 40 mm. No intrastent CTO was noticed, and a previous attempt was performed in 2 patients (25%). In Table 1 the patients’ baseline characteristics are summarized. Procedural details A double femoral 7-French access was performed in all patients. An antegrade approach was attempted in 4 cases (50%), and a retrograde strategy was performed in 4 patients (50%). The dissection involved the right sinus of Valsalva in 7 cases (antegrade, n ¼ 4; retrograde, n ¼ 3) and the left sinus was involved in the remaining retrograde case. The catheters
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Table 1. Characteristics of patients experiencing iatrogenic aortic dissection Case
Sex
Age
CTO vessel
Ostial location
Severe calcifications
CTO length > 40 mm
1 2 3 4 5 6 7 8
M M M M F M F M
62 66 65 59 63 53 71 69
RCA RCA RCA RCA RCA RCA RCA RCA
No No Yes No Yes No No Yes
No Yes Yes No Yes No Yes Yes
No Yes Yes Yes Yes No Yes No
RCA dissection (n ¼ 1). Intravascular ultrasound assessment of the dissection was performed in 2 cases (cases 3 and 8; Fig. 2). The coronary ostium was stented in all cases: drug eluting stents were implanted in 6 cases, and in 2 cases covered stents were used. None of the patients received protamine. Because no patients showed hemodynamic instability, the procedure was continued in all cases, and angiographic success was achieved in 7 patients (87.5%). Table 2 shows the procedural details of patients who experienced iatrogenic aortic dissection.
CTO, chronic total occlusion; F, female; M, male; RCA, right coronary artery.
In-hospital and long-term outcome
engaged in the coronary ostium were as follows: right ostium (Judkins right 4 [Cordis, Miami, FL] [n ¼ 5]; right Amplatz 1 [Cordis] [n ¼ 1]; left Amplatz 1 [n ¼ 1]); left ostium (extra backup 5 [n ¼ 1]) (Fig. 1). The manipulation of the catheter was judged to be difficult with a poor backup in 5 cases (62.5%). CTO dedicated devices were used in 6 cases (75%): microcatheter Corsair (Asahi Intecc, Aichi, Japan; n ¼ 3), Crosser (Bard Peripheral Vascular, Inc, Tempe, AZ; n ¼ 2), and Tornus (Asahi Intecc, Aichi, Japan; n ¼ 1). The presumed mechanisms of iatrogenic aortic dissection were as follows: guiding catheter trauma (n ¼ 6), contrast injection with a wedged catheter (n ¼ 1), and a retrograde projection of
A conservative strategy was adopted in all patients and no emergency surgery was required. The mean intensive care unit stay and hospitalization duration were 2.2 days (range, 2-4 days) and 7.2 days (range, 5-10 days), respectively. Immediate aortic imaging was obtained in all patients: CT angiogram was performed in 7 patients, and the remaining patient (case 2) underwent a transesophageal echocardiography (TEE) because of impaired renal function (Figs. 3 and 4). A dissection class 1 was observed in 2 patients, and class 2 in 6 patients. Antiplatelet agents were not interrupted: aspirin (100 mg daily) was prescribed lifelong, and clopidogrel (75 mg daily) for 12 months in patients with successful CTO recanalization. The in-hospital stay was uneventful in all patients, and a comparative aortic imaging, before discharge was
Figure 1. (A) Case 3. Antero-posterior cranial view showing iatrogenic aortic dissection class 2 caused by a retrograde approach of proximal CTO lesion of the RCA. Guide catheter: left Amplatz 1 (Cordis, Miami, FL). Presumed mechanism: contrast injection with a wedged catheter. (B) Case 4. Left anterior oblique view showing iatrogenic aortic dissection class 1 (limited to right sinus of Valsalva) caused by an antegrade approach of the ostial CTO lesion of the RCA. Guide catheter: Judkins right 4 (Cordis). Presumed mechanism: catheter trauma. (C) Case 7. Anteroposterior view showing iatrogenic dissection class 2 with a parietal hematoma (arrow) caused by a retrograde approach of the proximal CTO lesion of the RCA. Guide catheter: right Amplatz 1. Presumed mechanism: catheter trauma. CTO, chronic total occlusion; RCA, right coronary artery.
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Figure 2. Case 3. IVUS assessment after ostial implantation of a drug-eluting stent. (A) Right anterior oblique view angiogram showing a final TIMI 3 flow after chronic total occlusion recanalization of the right coronary artery. IVUS cross-sections S1 and S2 are located within the ostial stent in the proximal right coronary artery and in aorta, respectively. (B) IVUS cross-sections S1 and S2 within the ostial stent without contrast injection. (C) Transverse IVUS section (S1) showing the ostial stent implanted in the false lumen and compressing the true lumen. (D) Transverse IVUS crosssection (S2) showing the implantation of the ostial stent protruding in the aorta, reaching to achieve sealing of the entry point of the dissection. IVUS, intravascular ultrasound; TIMI, Thrombolysis in Myocardial Infarction.
Table 2. Procedural details of patients who experienced iatrogenic aortic dissection Case
CTO approach
Dissected sinus
Guiding catheter
CTO device
1 2 3 4 5 6 7 8
Antegrade Antegrade Retrograde Antegrade Retrograde Antegrade Retrograde Retrograde
Right Right Right Right Left Right Right Right
JR 4 JR 4 AL 1 JR 4 EBU 5 JR 4 JR 4 AR 1
Crosser Crosser Corsair d Corsair d Corsair Tornus
Presumed mechanism Catheter trauma Catheter trauma Contrast injection and wedged catheter Catheter trauma Catheter trauma Catheter trauma Catheter trauma Retrograde projection of RCA dissection
IVUS use
Ostium stenting
No No Yes No No No No Yes
DES DES Covered stent DES DES DES DES Covered stent
Final TIMI flow 3 3 3 3 3 3 0 3
Crosser device from Bard Peripheral Vascular, Inc (Tempe, AZ); Corsair and Tomus devices from Asahi Intecc (Aichi, Japan). AL, left Amplatz (Cordis, Miami, FL); AR, right Amplatz; CTO, chronic total occlusion; DES, drug-eluting stent; EBU, extra backup; IVUS, intravascular ultrasound; JR, Judkins right (Cordis); RCA, right coronary artery; TIMI, Thrombolysis in Myocardial Infarction.
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obtained in 5 patients (Table 3), showing the absence of aortic dissection extension in all cases. After discharge, a sudden cardiac death occurred in a 71-year-old woman with Dunning class 2 dissection, complicating an unsuccessful retrograde attempt to revascularize RCA CTO (case 7), 12 days after the index procedure; and no major adverse cardiac and cerebral events were noticed in the remaining 7 patients, who were asymptomatic after a mean follow-up of 31.6 months (range, 3-52 months; Table 3). At 1-month follow-up of the 7 survivors, control CT angiography was performed in 4 patients (all of them Dunning class 2), showing total resolution in 3 patients, and partial resolution in the remaining patient (case 3). In this latter case, total resolution of the dissected thrombosed lumen was shown in the 6-month control CT angiogram (Fig. 5).
Figure 3. Case 8. Computed tomography angiogram frontal reconstruction 24 hours after iatrogenic aortic dissection: (A) unenhanced scan examination shows intimal dislocation with eccentric double lumen extending up to 34 mm in the ascending aorta (Dunning class 2), better seen after contrast injection (B).
Discussion The current case series showed the experience of a single CTO dedicated operator in managing patients who experienced iatrogenic aortic dissection during CTO recanalization procedures. Iatrogenic aortic dissection remains rare. Indeed, in a report of 43,143 cardiac catheterization and PCIs, only 9 cases of iatrogenic aortic dissections were reported with an incidence of 0.02%.15 The same frequency was observed in another study including 21,000 PCIs16; and Carter et al.17 showed an incidence of 0.02% for diagnostic angiography and 0.07% for coronary angioplasty cases. In the current study, the prevalence of iatrogenic aortic dissection was relatively high (0.83%). In a single-centre experience of 336 consecutive CTO procedures, Shorrock et al.18 reported a greater incidence of 1.8%. Furthermore, in a meta-analysis of 26 studies including 3482 patients who underwent retrograde CTO PCI, the pooled estimate rate of this complication was 1.9%.19 One of the possible explanations of such high frequencies might be a more aggressive and extensive atherosclerosis in CTO patients, as suggested by Wilson and Hutchins.20 It is well established that CTO PCIs are more complex and challenging procedures than those for stenotic lesions. Moreover,
Figure 4. Case 2. Transesophageal echocardiogram immediately after the procedure. (A) The long-axis view of the left ventricular outflow tract and ascending aorta shows a class 2 dissection (30 mm) without aortic valve involvement. (B) The short-axis view shows a metallic stent inserted at the ostium of the right coronary artery projecting in the right Valsalva sinus.
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Table 3. Outcome in patients who experienced iatrogenic aortic dissection Case 1 2 3 4 5 6 7 8
Dunning classification
Days in hospital
2 2 2 1 2 1 2 2
9 10 7 6 9 7 5 5
Imaging after procedure
In-hospital imaging control*
In-hospital MACCE
Imaging follow-up
Clinical follow-up
Outcome
CT scan TEE CT scan CT scan CT scan CT scan CT scan CT scan
CT scan (2 days) TEE (1 day) CT scan (3 days) No CT scan (2 days) No No CT scan (3 days)
None None None None None None None None
CT scan No CT scan No CT scan No d CT scan
52 months 48 months 36 months 32 months 28 months 22 months 12 days 3 months
Uneventful Uneventful Uneventful Uneventful Uneventful Uneventful Cardiac death (12 days) Uneventful
CT, computed tomography; MACCE, major adverse cardiac and cerebral event; TEE, trans-esophageal echocardiography. * The delay between brackets represents the interval between the first and the second aortic imaging assessment.
the presence of severe calcifications and the use of dedicated devices require further support, leading to more aggressive manipulations; thus, a greater risk of procedural complications, regardless of the type of guiding catheter. In contrast to the literature, when Amplatz catheters (particularly left Amplatz) are reported to be associated with a higher risk of dissection, the Judkins right guiding catheter was used in most of our cases. Indeed, guiding catheter trauma represents the most common etiology of iatrogenic aortic dissection.21-23 The other possible causes can be summarized as follows:
Figure 5. Case 3. CT angiogram follow-up. (A) Twenty-four hours after the procedure, CT angiogram examination showing dislocation of intimal calcification with an eccentric double lumen. (B) One-month CT control examination demonstrating almost total resolution of the dissected thrombosed lumen. (C) Six-month CT control examination demonstrating total resolution of the dissection. CT, computed tomography.
contrast injection with a wedged catheter, retrograde progression of RCA dissection, and balloon rupture.24 In our study, the dissection started from the right sinus in 87.5% of cases, and the left sinus was involved in only 1 case retrogradely attempted (case 5). In Shorrock and colleagues’ case series, aortocoronary dissection only occurred in the RCA.18 Similarly, most iatrogenic aortic dissection complicating continuous lesion angioplasties involved the RCA.25 Moreover, the RCA ostium dissection has a higher likelihood to evolve into aortic dissection, because the hemodynamic force vector is directed to the right side convexity of the ascending aorta.15 The retrograde approach was used in 50% of our patients. According to the literature, aortic dissection was more common in patients who underwent retrograde CTO PCI.19 Indeed, the retrograde strategy was adopted in 67% of aortic dissection cases described by Shorrock et al.18 Prevention of such a complication requires particular attention not only to the retrograde catheter guide, but also to pressure waveform to avoid dangerous injections.18,19 Although the pathophysiology of iatrogenic aortic dissection is different from that of a spontaneous one, successful treatment of both of them, whether surgical or percutaneous, relies on the sealing of the entry site, leading to false lumen thrombosis and preventing possible dissected plane rupture. In our patients, rapid ostial stenting was performed in all cases; this strategy might avoid a rapid spread of dissection into aorta and the need for emergency surgery. Conversely, in Shorrock and colleagues’ report, ostial stenting was performed in 4 of 6 patients (67%); the in-hospital outcome was uneventful in 1 of the remaining 2 patients, and the other required emergency cardiac surgery.18 In addition to bare stents,24,25 covered stents, used in 2 of our patients (case 3 and 8), and in other reports,20,26 can represent a reliable option to ensure a seal of the dissection entry point. Intravascular ultrasound might be a useful tool for a better anatomical evaluation of the entry port, the dissection extension, and for further assessment after ostium stenting. The outcome of patients who experience aortic dissection during CTO PCI for stable coronary artery disease, seems to be better than for those with acute coronary syndromes.15 This fact might be because of a more aggressive antithrombotic therapy used in the latter setting. In all of our patients, no protamine administration was required and antiplatelet agents could be maintained despite aortic dissection.
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CT angiogram and TEE are both reliable tools to evaluate the dissection extension into the aorta. In our case series, aortic imaging was obtained in all patients immediately after the procedure. In contrast, Shorrock et al.18 performed TEE in only 33% of cases. Dunning class 3 is associated with a worse prognosis, and surgical intervention is generally required, when the dissection extends more than 40 mm in the ascending aorta.15 However, Park et al.27 reported a good outcome of a CTO patient who experienced aortic dissection involving the entire ascending aorta, successfully managed using a conservative strategy. A more recent case was reported by Wykrzykowska et al.,28 underscoring the strategy consisting of patching up the coronary problem, and “wait and see” in close intervals using CT scan or TEE, if the dissected aortic wall segment will heal.28 We used such a strategy in Dunning class 1 and 2 patients, and achieved short- and long-term good outcomes (87.5% of our patients). In the absence of autopsy proof, it is not possible to know the real cause of the cardiac death observed in case 7, however, the extension of the dissection or the aortic rupture could be assumed as possible causes of such an outcome. Notably, although the final angiogram in this patient showed the absence of contrast filling of the dissection, suggesting sealing of the entry point, a parietal hematoma was observed (Fig. 1C). This unusual presentation is related to iatrogenic bleeding within the media, and might lead to aortic wall weakening with a high risk of outward aortic rupture, as described by Alomari et al.29 in a different setting of spontaneous parietal aortic hematoma. CT angiography performed 2 days after the index procedure revealed extension of the dissection 35 mm into the ascending aorta; however, this patient had the shortest duration of hospitalization (5 days) and CT angiography was not repeated before discharge. Although we cannot confirm that this death could have been prevented using a comparative imaging control before discharge, this case might underline that a higher level of surveillance should be reserved for patients with Dunning class 2 status. Moreover, in the presence of parietal hematoma, surgical treatment might be considered regardless of the degree of dissection extension into the aorta. Further imaging control (in-hospital and during follow-up) was performed in most survivors, particularly in those with Dunning class 2 dissection, and showed complete or partial resolution in all cases. This fact underlines the importance of serial assessments to detect progressive extension of aortic dissection30 (using TEE or CT scan), to recognize cases in which a surgical procedure should be mandatory. Iatrogenic aortic dissection is a rare but potentially serious complication of coronary angiography and intervention. More complex and “cumbersome” CTO recanalization procedures, even in experienced hands, might be associated with a greater incidence of such a complication. CT angiogram and TEE are optimal tools to classify and to follow the extension of the dissection, because the therapeutic strategy and outcome depend on the rapidity of the entry point sealing and the degree of extension of the dissection into the aorta in serial imaging assessment. Disclosures The authors have no conflicts of interest to disclose.
Canadian Journal of Cardiology Volume 31 2015
References 1. Chung CM, Nakamura S, Tanaka K, et al. Effect of recanalization of chronic total occlusions on global and regional left ventricular function in patients with or without previous myocardial infarction. Catheter Cardiovasc Interv 2003;60:368-74. 2. Galassi AR, Tomasello SD, Crea F, et al. Transient impairment of vasomotion function after successful chronic total occlusion recanalization. J Am Coll Cardiol 2012;59:711-8. 3. Cheng AS, Selvanayagam JB, Jerosch-Herold M, et al. Percutaneous treatment of chronic total coronary occlusions improves regional hyperemic myocardial blood flow and contractility: insights from quantitative cardiovascular magnetic resonance imaging. JACC Cardiovasc Interv 2008;1:44-53. 4. Baks T, van Geuns RJ, Duncker DJ, et al. Prediction of left ventricular function after drug-eluting stent implantation for chronic total coronary occlusions. J Am Coll Cardiol 2006;47:721-5. 5. Pristipino C, Granatelli A, Capasso M, et al. Effects of reperfusion obtained two to six months after acute myocardial infarction on myocardial electrical stabilization in patients with an occluded infarct-related coronary artery. Am J Cardiol 2005;96:769-72. 6. Tomasello SD, Giudice P, Attisano T, Boukhris M, Galassi AR. The innovation of composite core dual coil coronary guide-wire technology: a didactic coronary chronic total occlusion revascularization case report. J Saudi Heart Assoc 2014;26:222-5. 7. Galassi AR, Ganyukov V, Tomasello SD, Haes B, Leonid B. Successful antegrade revascularization by the innovation of composite core dual coil in a three-vessel total occlusive disease for cardiac arrest patient using extracorporeal membrane oxygenation. Eur Heart J 2014;35:2009. 8. Galassi AR, Tomasello SD, Costanzo L, et al. Mini-STAR as bail-out strategy for percutaneous coronary intervention of chronic total occlusion. Catheter Cardiovasc Interv 2012;79:30-40. 9. Galassi AR, Boukhris M, Tomasello SD, et al. Long term clinical and angiographic outcome of the Mini-STAR technique as a bail out strategy for percutaneous coronary intervention of chronic total occlusion. Can J Cardiol 2014;30:1400-6. 10. Galassi AR, Tomasello SD, Costanzo L, et al. Long-term clinical and angiographic results of Sirolimus-Eluting Stent in Complex Coronary Chronic Total Occlusion Revascularization: the SECTOR registry. J Interv Cardiol 2011;24:426-36. 11. Galassi AR, Tomasello SD, Reifart N, et al. In-hospital outcomes of percutaneous coronary intervention in patients with chronic total occlusion: insights from the ERCTO (European Registry of Chronic Total Occlusion) registry. EuroIntervention 2011;7:472-9. 12. Frangieh AH, Klainguti M, Lüscher TF, Galassi AR, Gaemperli O. Leftsided haemothorax after iatrogenic coronary perforation in a patient with prior bypass surgery [e-pub ahead of print]. Eur Heart J; 2014 Aug 24. 13. Perez-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;43:273-9. 14. Sianos G, Werner GS, Galassi AR, et al. Recanalisation of chronic total coronary occlusions: 2012 consensus document from the EuroCTO club. EuroIntervention 2012;8:139-45. 15. Dunning DW, Kahn JK, Hawkins ET, O’Neill WW. Iatrogenic coronary artery dissections extending into and involving the aortic root. Catheter Cardiovasc Interv 2000;51:387-93.
Boukhris et al. Iatrogenic Aortic Dissection in CTO PCI 16. Vega MR. Aortic dissection: exceedingly rare complication of coronary angioplasty. Cathet Cardiovasc Diagn 1997;42:416. 17. Carter AJ, Brinker JA. Dissection of the ascending aorta associated with coronary angiography. Am J Cardiol 1994;73:922-3. 18. Shorrock D, Michael TT, Patel V, et al. Frequency and outcomes of aortocoronary dissection during percutaneous coronary intervention of chronic total occlusions: a case series and systematic review of the literature. Catheter Cardiovasc Interv 2014;84:670-5. 19. El Sabbagh A, Patel VG, Jeroudi OM, et al. Angiographic success and procedural complications in patients undergoing retrograde percutaneous coronary chronic total occlusion interventions: a weighted meta-analysis of 3,482 patients from 26 studies. Int J Cardiol 2014;174:243-8. 20. Wilson SK, Hutchins GM. Aortic dissecting aneurysms: causative factors in 204 subjects. Arch Pathol Lab Med 1982;106:175-80. 21. Oda H, Hatada K, Sakai K, et al. Aortocoronary dissection resolved by coronary stenting guided by intracoronary ultrasound. Circ J 2004;68: 389-91. 22. Chunlai S, Stella PR, Belkacemi A, Agostoni P. Aortic dissection, a complication during successful angioplasty of chronic total occlusion of the right coronary artery, was treated conservatively. Cardiovasc J Afr 2012;23:11-3.
327
23. Bryniarski L, Dragan J, Dudek D. Dissection of the right coronary ostium and sinus of Valsalva during right coronary artery angioplasty. J Invasive Cardiol 2008;20:277-80. 24. Abdou SM, Wu CJ. Treatment of aortocoronary dissection complicating anomalous origin right coronary artery and chronic total intervention with intravascular ultrasound guided stenting. Catheter Cardiovasc Interv 2011;78:914-9. 25. Carstensen S, Ward MR. Iatrogenic aortocoronary dissection: the case for immediate aorto-ostial stenting. Heart Lung Circ 2008;17:325-9. 26. Abu-Ful A, Weinstein JM, Henkin Y. Covered stent: a novel percutaneous treatment of iatrogenic aortic dissection during coronary angioplasty. J Invasive Cardiol 2003;15:408-9. 27. Park IW, Min PK, Cho DK, Byun KH. Successful endovascular treatment of iatrogenic coronary artery dissection extending into the entire ascending aorta. Can J Cardiol 2008;24:857-9. 28. Wykrzykowska JJ, Ligthart J, Lopez NG, et al. How should I treat an iatrogenic aortic dissection as a complication of complex PCI? EuroIntervention 2012;7:1111-7. 29. Alomari IB, Hamirani YS, Madera G, et al. Aortic intramural hematoma and its complications. Circulation 2014;129:711-6. 30. Garg P, Buckley O, Rybicki FJ, Resnic FS. Resolution of iatrogenic aortic dissection illustrated by computed tomography. Circ Cardiovasc Interv 2009;2:261-3.
Clinical Research
Iatrogenic Aortic Dissection Complicating Percutaneous Coronary Intervention for Chronic Total Occlusion Marouane Boukhris, MD,a,b Salvatore Davide Tomasello, MD,a Francesco Marzà, MD,a Salvatore Azzarelli, MD,a and Alfredo Ruggero Galassi, MD, FACC, FESC, FSCAIa a
Department of Medical Sciences and Pediatrics, Catheterization Laboratory and Cardiovascular Interventional Unit, Division of Cardiology, Cannizzaro Hospital, University of Catania, Catania, Italy b
Faculty of Medicine of Tunis, University Tunis El Manar, Tunis, Tunisia
ABSTRACT
RESUM E
Background: We aimed to determine the prevalence of iatrogenic aortic dissection in chronic total occlusion (CTO) recanalization procedures, and to assess the management strategy and outcome of such a complication. Methods: This study was a retrospective analysis of CTO percutaneous coronary intervention (PCI) cases performed by a single CTO experienced operator. Iatrogenic aortic dissection was defined as persistent contrast staining in the aortic cusp or root. Results: Among 956 CTO PCI cases, iatrogenic aortic dissection occurred in 8 patients for an overall frequency of 0.83%. The right coronary artery was the CTO involved vessel in all cases with ostial location and severe calcifications in 37.5% and 62.5% of cases, respectively. Four patients underwent the antegrade approach and a retrograde strategy was adopted in the remaining 4 patients. The iatrogenic aortic dissection started from the right sinus of Valsalva in 87.5% of cases and catheter trauma was the presumed mechanism of dissection in most cases. Stenting of the entry point was performed in all cases, and dissection was limited (< 40 mm) in all patients. No patients required emergency surgery. One cardiac death was observed 12 days after the index procedure (12.5%), and a mean follow-up of 31.5 months was uneventful in the remaining 7 patients.
tait de de terminer la pre valence de la Introduction : Notre but e dissection iatrogène de l’aorte lors des interventions de recanalisation valuer la strate gie de d’une occlusion totale chronique (OTC) et d’e sultats de cette complication. prise en charge et les re thodes : L’e tude dont il est question ici e tait une analyse Me trospective des cas d’interventions coronariennes percutane es (ICP) re alise es par un seul ope rateur expe rimente dans les d’OTC. La d’OTC re tait de finie comme une coloration de dissection iatrogène de l’aorte e contraste persistante de la cuspide ou de la racine aortiques. sultats : Parmi les 956 cas d’ICP d’OTC, la dissection iatrogène de Re quence globale de 0,83 %. l’aorte survenait chez 8 patients selon une fre tait le vaisseau touche par l’OTC dans tous L’artère coronaire droite e s à l’ostium et ayant des calcifications graves, soit dans les cas situe 37,5 % et 62,5 % des cas, respectivement. Quatre patients subissaient rograde, puis les 4 patients restants sul’approche par voie ante trograde. La dissection iatrogène de bissaient une approche par voie re l’aorte partait du sinus de Valsalva droit dans 87,5 % des cas et le ter e tait le me canisme pre sume de la dissectraumatisme par cathe tion dans la plupart des cas. L’implantation de l’endoprothèse au point e e tait re alise e dans tous les cas, et la dissection e tait limite e d’entre (< 40 mm) chez tous les patients. Aucun patient n’avait besoin d’une
It is well demonstrated that successful revascularization of chronic total occlusion (CTO) improves left ventricular function,1 increased myocardial perfusion,2,3 reduced left ventricular remodelling,4 and increased electrical stability.5 However, despite the development of techniques and equipment6-8 with high success rates (75%-90%) achieved by
experienced operators,9,10 percutaneous coronary intervention (PCI) in CTO lesions remains associated with a greater incidence of procedural complications compared with nonCTO PCI.11,12 Dissection of the ascending aorta is a very rare iatrogenic complication of PCI with an incidence of 0.03%-0.06%.13 The trigger of such a complication is a dissection of the coronary sinus of Valsalva, which progressively extends to the ascending aorta. The appropriate therapeutic strategy is still controversial. The aim of this study was to determine the prevalence of aortic dissection occurring in CTO revascularization procedures and to assess the management strategy and the outcome of such a complication.
Received for publication October 1, 2014. Accepted November 30, 2014. Corresponding author: Dr Alfredo Ruggero Galassi, Via Antonello da Messina 75, Acicastello, 95021 Catania, Italy. Tel.: þ39-095-7263122-3623; fax: þ39-095-7263124-3633. E-mail: [email protected] See page 326 for disclosure information.
http://dx.doi.org/10.1016/j.cjca.2014.11.030 0828-282X/Ó 2015 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.
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Conclusions: CTO recanalization procedures might be associated with a greater incidence of iatrogenic aortic dissection than non-CTO PCI. The therapeutic strategy and outcome depend on the rapidity of the entry point sealing and the degree of extension of the dissection into the aorta in serial imaging assessment.
tait observe e 12 jours après chirurgie d’urgence. Une mort cardiaque e fe rence (12,5 %), et un suivi moyen de 31,5 mois l’intervention de re tait de roule sans incident chez les 7 patients restants. s’e Conclusions : Les interventions de recanalisation d’OTC seraient es à une plus grande fre quence de dissection iatrogène de associe gie the rapeutique et les l’aorte que les non-ICP d’OTC. La strate sultats de pendent de la rapidite de la fermeture du point d’entre e et re d’extension de la dissection de l’aorte à l’e valuation de du degre rielle. l’imagerie se
Methods
administered if patients were not pretreated. The choice of the guiding catheter, the CTO recanalization approach, the use of CTO devices, and the choice of aortic dissection treatment were completely based on the operator’s discretion and experience.
Study population This study was a retrospective analysis of CTO PCI cases performed by a single CTO experienced operator, from January 2006 to April 2014. Iatrogenic aortic dissection was defined as persistent contrast staining in the aortic cusp or root. Definitions CTO was defined as a coronary obstruction with Thrombolysis in Myocardial Infarction (TIMI) flow grade 0 with an estimated duration > 3 months.14 The indication for the percutaneous treatment of CTO was based on the demonstration of viable myocardium in the territory of the occluded vessel using echographic or scintigraphic provocative tests, whereas no CTO angiographic characteristic was considered as an absolute contraindication to attempt PCI. Angiographic success was defined as a residual stenosis < 30% with a final TIMI flow grade 3 at the end of the procedure. Two experienced interventional cardiologists evaluated together the cine films of patients who experienced iatrogenic aortic dissection, as a consequence of the CTO recanalization procedure; and a cardiologist involved in cardiovascular imaging reviewed their echocardiograms and computed tomography (CT) angiograms. The Dunning classification15 was used to describe the extension of aortic dissection: class 1 was defined as a focal dissection restricted to the coronary cusp; in class 2 the dissection extended up the ascending aorta but < 40 mm; and class 3 included dissections extending from the coronary cusp up to the ascending aorta > 40 mm. Major adverse cardiac and cerebral events were defined as cardiac death, acute myocardial infarction, stroke, or further revascularization. Procedure All procedures were scheduled, and all patients were pretreated with 100 mg of aspirin daily. At the beginning of the procedure, patients received intravenous unfractionated heparin (80-100 IU/kg) to maintain activated clotting time > 300 seconds, and activated clotting time was monitored every 30 minutes to determine if an additional bolus of unfractionated heparin was necessary. No patients were treated with glycoprotein IIb/IIIa inhibitors or bivalirudin. A 600-mg loading dose of clopidogrel before the procedure was
Statistical analysis Continuous variables were presented as mean and ranges. Categorical variables were presented as counts and percentages. All data were processed using the Statistical Package for Social Sciences, version 21 (SPSS, Chicago, IL). Results Prevalence of iatrogenic aortic dissection and characteristics Among 956 patients with at least 1 CTO lesion, treated by a single CTO dedicated experienced operator, iatrogenic aortic dissection was diagnosed in 8 patients for an overall frequency of 0.83%. The mean age was 63.5 years (range, 53-71 years) and 6 patients (75%) were male. Four patients (50%) were diabetic; hypertension and dyslipidemia were observed in 87.5% and 62.5% of cases, respectively; and 5 patients (62.5%) were current smokers. A history of myocardial infarction was noticed in 3 patients (37.5%), and all patients underwent previous revascularization: previous PCI in 4 cases (50%), and previous coronary artery bypass in 4 cases (50%). The clinical presentation was stable angina in all patients: Canadian Cardiovascular Society class 2 in 7 patients (87.5%), and Canadian Cardiovascular Society class 3 in the remaining patient (12.5%). The mean left ventricular ejection fraction was 52.5% (range, 45%-55%). All patients had multivessel disease with 1 CTO lesion, and the right coronary artery (RCA) was the target vessel in all cases. An ostial CTO location was observed in 3 cases (37.5%); severe calcification in 5 cases (62.5%); and 5 patients (62.5%) had a CTO length 40 mm. No intrastent CTO was noticed, and a previous attempt was performed in 2 patients (25%). In Table 1 the patients’ baseline characteristics are summarized. Procedural details A double femoral 7-French access was performed in all patients. An antegrade approach was attempted in 4 cases (50%), and a retrograde strategy was performed in 4 patients (50%). The dissection involved the right sinus of Valsalva in 7 cases (antegrade, n ¼ 4; retrograde, n ¼ 3) and the left sinus was involved in the remaining retrograde case. The catheters
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Table 1. Characteristics of patients experiencing iatrogenic aortic dissection Case
Sex
Age
CTO vessel
Ostial location
Severe calcifications
CTO length > 40 mm
1 2 3 4 5 6 7 8
M M M M F M F M
62 66 65 59 63 53 71 69
RCA RCA RCA RCA RCA RCA RCA RCA
No No Yes No Yes No No Yes
No Yes Yes No Yes No Yes Yes
No Yes Yes Yes Yes No Yes No
RCA dissection (n ¼ 1). Intravascular ultrasound assessment of the dissection was performed in 2 cases (cases 3 and 8; Fig. 2). The coronary ostium was stented in all cases: drug eluting stents were implanted in 6 cases, and in 2 cases covered stents were used. None of the patients received protamine. Because no patients showed hemodynamic instability, the procedure was continued in all cases, and angiographic success was achieved in 7 patients (87.5%). Table 2 shows the procedural details of patients who experienced iatrogenic aortic dissection.
CTO, chronic total occlusion; F, female; M, male; RCA, right coronary artery.
In-hospital and long-term outcome
engaged in the coronary ostium were as follows: right ostium (Judkins right 4 [Cordis, Miami, FL] [n ¼ 5]; right Amplatz 1 [Cordis] [n ¼ 1]; left Amplatz 1 [n ¼ 1]); left ostium (extra backup 5 [n ¼ 1]) (Fig. 1). The manipulation of the catheter was judged to be difficult with a poor backup in 5 cases (62.5%). CTO dedicated devices were used in 6 cases (75%): microcatheter Corsair (Asahi Intecc, Aichi, Japan; n ¼ 3), Crosser (Bard Peripheral Vascular, Inc, Tempe, AZ; n ¼ 2), and Tornus (Asahi Intecc, Aichi, Japan; n ¼ 1). The presumed mechanisms of iatrogenic aortic dissection were as follows: guiding catheter trauma (n ¼ 6), contrast injection with a wedged catheter (n ¼ 1), and a retrograde projection of
A conservative strategy was adopted in all patients and no emergency surgery was required. The mean intensive care unit stay and hospitalization duration were 2.2 days (range, 2-4 days) and 7.2 days (range, 5-10 days), respectively. Immediate aortic imaging was obtained in all patients: CT angiogram was performed in 7 patients, and the remaining patient (case 2) underwent a transesophageal echocardiography (TEE) because of impaired renal function (Figs. 3 and 4). A dissection class 1 was observed in 2 patients, and class 2 in 6 patients. Antiplatelet agents were not interrupted: aspirin (100 mg daily) was prescribed lifelong, and clopidogrel (75 mg daily) for 12 months in patients with successful CTO recanalization. The in-hospital stay was uneventful in all patients, and a comparative aortic imaging, before discharge was
Figure 1. (A) Case 3. Antero-posterior cranial view showing iatrogenic aortic dissection class 2 caused by a retrograde approach of proximal CTO lesion of the RCA. Guide catheter: left Amplatz 1 (Cordis, Miami, FL). Presumed mechanism: contrast injection with a wedged catheter. (B) Case 4. Left anterior oblique view showing iatrogenic aortic dissection class 1 (limited to right sinus of Valsalva) caused by an antegrade approach of the ostial CTO lesion of the RCA. Guide catheter: Judkins right 4 (Cordis). Presumed mechanism: catheter trauma. (C) Case 7. Anteroposterior view showing iatrogenic dissection class 2 with a parietal hematoma (arrow) caused by a retrograde approach of the proximal CTO lesion of the RCA. Guide catheter: right Amplatz 1. Presumed mechanism: catheter trauma. CTO, chronic total occlusion; RCA, right coronary artery.
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Figure 2. Case 3. IVUS assessment after ostial implantation of a drug-eluting stent. (A) Right anterior oblique view angiogram showing a final TIMI 3 flow after chronic total occlusion recanalization of the right coronary artery. IVUS cross-sections S1 and S2 are located within the ostial stent in the proximal right coronary artery and in aorta, respectively. (B) IVUS cross-sections S1 and S2 within the ostial stent without contrast injection. (C) Transverse IVUS section (S1) showing the ostial stent implanted in the false lumen and compressing the true lumen. (D) Transverse IVUS crosssection (S2) showing the implantation of the ostial stent protruding in the aorta, reaching to achieve sealing of the entry point of the dissection. IVUS, intravascular ultrasound; TIMI, Thrombolysis in Myocardial Infarction.
Table 2. Procedural details of patients who experienced iatrogenic aortic dissection Case
CTO approach
Dissected sinus
Guiding catheter
CTO device
1 2 3 4 5 6 7 8
Antegrade Antegrade Retrograde Antegrade Retrograde Antegrade Retrograde Retrograde
Right Right Right Right Left Right Right Right
JR 4 JR 4 AL 1 JR 4 EBU 5 JR 4 JR 4 AR 1
Crosser Crosser Corsair d Corsair d Corsair Tornus
Presumed mechanism Catheter trauma Catheter trauma Contrast injection and wedged catheter Catheter trauma Catheter trauma Catheter trauma Catheter trauma Retrograde projection of RCA dissection
IVUS use
Ostium stenting
No No Yes No No No No Yes
DES DES Covered stent DES DES DES DES Covered stent
Final TIMI flow 3 3 3 3 3 3 0 3
Crosser device from Bard Peripheral Vascular, Inc (Tempe, AZ); Corsair and Tomus devices from Asahi Intecc (Aichi, Japan). AL, left Amplatz (Cordis, Miami, FL); AR, right Amplatz; CTO, chronic total occlusion; DES, drug-eluting stent; EBU, extra backup; IVUS, intravascular ultrasound; JR, Judkins right (Cordis); RCA, right coronary artery; TIMI, Thrombolysis in Myocardial Infarction.
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obtained in 5 patients (Table 3), showing the absence of aortic dissection extension in all cases. After discharge, a sudden cardiac death occurred in a 71-year-old woman with Dunning class 2 dissection, complicating an unsuccessful retrograde attempt to revascularize RCA CTO (case 7), 12 days after the index procedure; and no major adverse cardiac and cerebral events were noticed in the remaining 7 patients, who were asymptomatic after a mean follow-up of 31.6 months (range, 3-52 months; Table 3). At 1-month follow-up of the 7 survivors, control CT angiography was performed in 4 patients (all of them Dunning class 2), showing total resolution in 3 patients, and partial resolution in the remaining patient (case 3). In this latter case, total resolution of the dissected thrombosed lumen was shown in the 6-month control CT angiogram (Fig. 5).
Figure 3. Case 8. Computed tomography angiogram frontal reconstruction 24 hours after iatrogenic aortic dissection: (A) unenhanced scan examination shows intimal dislocation with eccentric double lumen extending up to 34 mm in the ascending aorta (Dunning class 2), better seen after contrast injection (B).
Discussion The current case series showed the experience of a single CTO dedicated operator in managing patients who experienced iatrogenic aortic dissection during CTO recanalization procedures. Iatrogenic aortic dissection remains rare. Indeed, in a report of 43,143 cardiac catheterization and PCIs, only 9 cases of iatrogenic aortic dissections were reported with an incidence of 0.02%.15 The same frequency was observed in another study including 21,000 PCIs16; and Carter et al.17 showed an incidence of 0.02% for diagnostic angiography and 0.07% for coronary angioplasty cases. In the current study, the prevalence of iatrogenic aortic dissection was relatively high (0.83%). In a single-centre experience of 336 consecutive CTO procedures, Shorrock et al.18 reported a greater incidence of 1.8%. Furthermore, in a meta-analysis of 26 studies including 3482 patients who underwent retrograde CTO PCI, the pooled estimate rate of this complication was 1.9%.19 One of the possible explanations of such high frequencies might be a more aggressive and extensive atherosclerosis in CTO patients, as suggested by Wilson and Hutchins.20 It is well established that CTO PCIs are more complex and challenging procedures than those for stenotic lesions. Moreover,
Figure 4. Case 2. Transesophageal echocardiogram immediately after the procedure. (A) The long-axis view of the left ventricular outflow tract and ascending aorta shows a class 2 dissection (30 mm) without aortic valve involvement. (B) The short-axis view shows a metallic stent inserted at the ostium of the right coronary artery projecting in the right Valsalva sinus.
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Table 3. Outcome in patients who experienced iatrogenic aortic dissection Case 1 2 3 4 5 6 7 8
Dunning classification
Days in hospital
2 2 2 1 2 1 2 2
9 10 7 6 9 7 5 5
Imaging after procedure
In-hospital imaging control*
In-hospital MACCE
Imaging follow-up
Clinical follow-up
Outcome
CT scan TEE CT scan CT scan CT scan CT scan CT scan CT scan
CT scan (2 days) TEE (1 day) CT scan (3 days) No CT scan (2 days) No No CT scan (3 days)
None None None None None None None None
CT scan No CT scan No CT scan No d CT scan
52 months 48 months 36 months 32 months 28 months 22 months 12 days 3 months
Uneventful Uneventful Uneventful Uneventful Uneventful Uneventful Cardiac death (12 days) Uneventful
CT, computed tomography; MACCE, major adverse cardiac and cerebral event; TEE, trans-esophageal echocardiography. * The delay between brackets represents the interval between the first and the second aortic imaging assessment.
the presence of severe calcifications and the use of dedicated devices require further support, leading to more aggressive manipulations; thus, a greater risk of procedural complications, regardless of the type of guiding catheter. In contrast to the literature, when Amplatz catheters (particularly left Amplatz) are reported to be associated with a higher risk of dissection, the Judkins right guiding catheter was used in most of our cases. Indeed, guiding catheter trauma represents the most common etiology of iatrogenic aortic dissection.21-23 The other possible causes can be summarized as follows:
Figure 5. Case 3. CT angiogram follow-up. (A) Twenty-four hours after the procedure, CT angiogram examination showing dislocation of intimal calcification with an eccentric double lumen. (B) One-month CT control examination demonstrating almost total resolution of the dissected thrombosed lumen. (C) Six-month CT control examination demonstrating total resolution of the dissection. CT, computed tomography.
contrast injection with a wedged catheter, retrograde progression of RCA dissection, and balloon rupture.24 In our study, the dissection started from the right sinus in 87.5% of cases, and the left sinus was involved in only 1 case retrogradely attempted (case 5). In Shorrock and colleagues’ case series, aortocoronary dissection only occurred in the RCA.18 Similarly, most iatrogenic aortic dissection complicating continuous lesion angioplasties involved the RCA.25 Moreover, the RCA ostium dissection has a higher likelihood to evolve into aortic dissection, because the hemodynamic force vector is directed to the right side convexity of the ascending aorta.15 The retrograde approach was used in 50% of our patients. According to the literature, aortic dissection was more common in patients who underwent retrograde CTO PCI.19 Indeed, the retrograde strategy was adopted in 67% of aortic dissection cases described by Shorrock et al.18 Prevention of such a complication requires particular attention not only to the retrograde catheter guide, but also to pressure waveform to avoid dangerous injections.18,19 Although the pathophysiology of iatrogenic aortic dissection is different from that of a spontaneous one, successful treatment of both of them, whether surgical or percutaneous, relies on the sealing of the entry site, leading to false lumen thrombosis and preventing possible dissected plane rupture. In our patients, rapid ostial stenting was performed in all cases; this strategy might avoid a rapid spread of dissection into aorta and the need for emergency surgery. Conversely, in Shorrock and colleagues’ report, ostial stenting was performed in 4 of 6 patients (67%); the in-hospital outcome was uneventful in 1 of the remaining 2 patients, and the other required emergency cardiac surgery.18 In addition to bare stents,24,25 covered stents, used in 2 of our patients (case 3 and 8), and in other reports,20,26 can represent a reliable option to ensure a seal of the dissection entry point. Intravascular ultrasound might be a useful tool for a better anatomical evaluation of the entry port, the dissection extension, and for further assessment after ostium stenting. The outcome of patients who experience aortic dissection during CTO PCI for stable coronary artery disease, seems to be better than for those with acute coronary syndromes.15 This fact might be because of a more aggressive antithrombotic therapy used in the latter setting. In all of our patients, no protamine administration was required and antiplatelet agents could be maintained despite aortic dissection.
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CT angiogram and TEE are both reliable tools to evaluate the dissection extension into the aorta. In our case series, aortic imaging was obtained in all patients immediately after the procedure. In contrast, Shorrock et al.18 performed TEE in only 33% of cases. Dunning class 3 is associated with a worse prognosis, and surgical intervention is generally required, when the dissection extends more than 40 mm in the ascending aorta.15 However, Park et al.27 reported a good outcome of a CTO patient who experienced aortic dissection involving the entire ascending aorta, successfully managed using a conservative strategy. A more recent case was reported by Wykrzykowska et al.,28 underscoring the strategy consisting of patching up the coronary problem, and “wait and see” in close intervals using CT scan or TEE, if the dissected aortic wall segment will heal.28 We used such a strategy in Dunning class 1 and 2 patients, and achieved short- and long-term good outcomes (87.5% of our patients). In the absence of autopsy proof, it is not possible to know the real cause of the cardiac death observed in case 7, however, the extension of the dissection or the aortic rupture could be assumed as possible causes of such an outcome. Notably, although the final angiogram in this patient showed the absence of contrast filling of the dissection, suggesting sealing of the entry point, a parietal hematoma was observed (Fig. 1C). This unusual presentation is related to iatrogenic bleeding within the media, and might lead to aortic wall weakening with a high risk of outward aortic rupture, as described by Alomari et al.29 in a different setting of spontaneous parietal aortic hematoma. CT angiography performed 2 days after the index procedure revealed extension of the dissection 35 mm into the ascending aorta; however, this patient had the shortest duration of hospitalization (5 days) and CT angiography was not repeated before discharge. Although we cannot confirm that this death could have been prevented using a comparative imaging control before discharge, this case might underline that a higher level of surveillance should be reserved for patients with Dunning class 2 status. Moreover, in the presence of parietal hematoma, surgical treatment might be considered regardless of the degree of dissection extension into the aorta. Further imaging control (in-hospital and during follow-up) was performed in most survivors, particularly in those with Dunning class 2 dissection, and showed complete or partial resolution in all cases. This fact underlines the importance of serial assessments to detect progressive extension of aortic dissection30 (using TEE or CT scan), to recognize cases in which a surgical procedure should be mandatory. Iatrogenic aortic dissection is a rare but potentially serious complication of coronary angiography and intervention. More complex and “cumbersome” CTO recanalization procedures, even in experienced hands, might be associated with a greater incidence of such a complication. CT angiogram and TEE are optimal tools to classify and to follow the extension of the dissection, because the therapeutic strategy and outcome depend on the rapidity of the entry point sealing and the degree of extension of the dissection into the aorta in serial imaging assessment. Disclosures The authors have no conflicts of interest to disclose.
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References 1. Chung CM, Nakamura S, Tanaka K, et al. Effect of recanalization of chronic total occlusions on global and regional left ventricular function in patients with or without previous myocardial infarction. Catheter Cardiovasc Interv 2003;60:368-74. 2. Galassi AR, Tomasello SD, Crea F, et al. Transient impairment of vasomotion function after successful chronic total occlusion recanalization. J Am Coll Cardiol 2012;59:711-8. 3. Cheng AS, Selvanayagam JB, Jerosch-Herold M, et al. Percutaneous treatment of chronic total coronary occlusions improves regional hyperemic myocardial blood flow and contractility: insights from quantitative cardiovascular magnetic resonance imaging. JACC Cardiovasc Interv 2008;1:44-53. 4. Baks T, van Geuns RJ, Duncker DJ, et al. Prediction of left ventricular function after drug-eluting stent implantation for chronic total coronary occlusions. J Am Coll Cardiol 2006;47:721-5. 5. Pristipino C, Granatelli A, Capasso M, et al. Effects of reperfusion obtained two to six months after acute myocardial infarction on myocardial electrical stabilization in patients with an occluded infarct-related coronary artery. Am J Cardiol 2005;96:769-72. 6. Tomasello SD, Giudice P, Attisano T, Boukhris M, Galassi AR. The innovation of composite core dual coil coronary guide-wire technology: a didactic coronary chronic total occlusion revascularization case report. J Saudi Heart Assoc 2014;26:222-5. 7. Galassi AR, Ganyukov V, Tomasello SD, Haes B, Leonid B. Successful antegrade revascularization by the innovation of composite core dual coil in a three-vessel total occlusive disease for cardiac arrest patient using extracorporeal membrane oxygenation. Eur Heart J 2014;35:2009. 8. Galassi AR, Tomasello SD, Costanzo L, et al. Mini-STAR as bail-out strategy for percutaneous coronary intervention of chronic total occlusion. Catheter Cardiovasc Interv 2012;79:30-40. 9. Galassi AR, Boukhris M, Tomasello SD, et al. Long term clinical and angiographic outcome of the Mini-STAR technique as a bail out strategy for percutaneous coronary intervention of chronic total occlusion. Can J Cardiol 2014;30:1400-6. 10. Galassi AR, Tomasello SD, Costanzo L, et al. Long-term clinical and angiographic results of Sirolimus-Eluting Stent in Complex Coronary Chronic Total Occlusion Revascularization: the SECTOR registry. J Interv Cardiol 2011;24:426-36. 11. Galassi AR, Tomasello SD, Reifart N, et al. In-hospital outcomes of percutaneous coronary intervention in patients with chronic total occlusion: insights from the ERCTO (European Registry of Chronic Total Occlusion) registry. EuroIntervention 2011;7:472-9. 12. Frangieh AH, Klainguti M, Lüscher TF, Galassi AR, Gaemperli O. Leftsided haemothorax after iatrogenic coronary perforation in a patient with prior bypass surgery [e-pub ahead of print]. Eur Heart J; 2014 Aug 24. 13. Perez-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;43:273-9. 14. Sianos G, Werner GS, Galassi AR, et al. Recanalisation of chronic total coronary occlusions: 2012 consensus document from the EuroCTO club. EuroIntervention 2012;8:139-45. 15. Dunning DW, Kahn JK, Hawkins ET, O’Neill WW. Iatrogenic coronary artery dissections extending into and involving the aortic root. Catheter Cardiovasc Interv 2000;51:387-93.
Boukhris et al. Iatrogenic Aortic Dissection in CTO PCI 16. Vega MR. Aortic dissection: exceedingly rare complication of coronary angioplasty. Cathet Cardiovasc Diagn 1997;42:416. 17. Carter AJ, Brinker JA. Dissection of the ascending aorta associated with coronary angiography. Am J Cardiol 1994;73:922-3. 18. Shorrock D, Michael TT, Patel V, et al. Frequency and outcomes of aortocoronary dissection during percutaneous coronary intervention of chronic total occlusions: a case series and systematic review of the literature. Catheter Cardiovasc Interv 2014;84:670-5. 19. El Sabbagh A, Patel VG, Jeroudi OM, et al. Angiographic success and procedural complications in patients undergoing retrograde percutaneous coronary chronic total occlusion interventions: a weighted meta-analysis of 3,482 patients from 26 studies. Int J Cardiol 2014;174:243-8. 20. Wilson SK, Hutchins GM. Aortic dissecting aneurysms: causative factors in 204 subjects. Arch Pathol Lab Med 1982;106:175-80. 21. Oda H, Hatada K, Sakai K, et al. Aortocoronary dissection resolved by coronary stenting guided by intracoronary ultrasound. Circ J 2004;68: 389-91. 22. Chunlai S, Stella PR, Belkacemi A, Agostoni P. Aortic dissection, a complication during successful angioplasty of chronic total occlusion of the right coronary artery, was treated conservatively. Cardiovasc J Afr 2012;23:11-3.
327
23. Bryniarski L, Dragan J, Dudek D. Dissection of the right coronary ostium and sinus of Valsalva during right coronary artery angioplasty. J Invasive Cardiol 2008;20:277-80. 24. Abdou SM, Wu CJ. Treatment of aortocoronary dissection complicating anomalous origin right coronary artery and chronic total intervention with intravascular ultrasound guided stenting. Catheter Cardiovasc Interv 2011;78:914-9. 25. Carstensen S, Ward MR. Iatrogenic aortocoronary dissection: the case for immediate aorto-ostial stenting. Heart Lung Circ 2008;17:325-9. 26. Abu-Ful A, Weinstein JM, Henkin Y. Covered stent: a novel percutaneous treatment of iatrogenic aortic dissection during coronary angioplasty. J Invasive Cardiol 2003;15:408-9. 27. Park IW, Min PK, Cho DK, Byun KH. Successful endovascular treatment of iatrogenic coronary artery dissection extending into the entire ascending aorta. Can J Cardiol 2008;24:857-9. 28. Wykrzykowska JJ, Ligthart J, Lopez NG, et al. How should I treat an iatrogenic aortic dissection as a complication of complex PCI? EuroIntervention 2012;7:1111-7. 29. Alomari IB, Hamirani YS, Madera G, et al. Aortic intramural hematoma and its complications. Circulation 2014;129:711-6. 30. Garg P, Buckley O, Rybicki FJ, Resnic FS. Resolution of iatrogenic aortic dissection illustrated by computed tomography. Circ Cardiovasc Interv 2009;2:261-3.
