Accepted Manuscript Treatment optimization of aorto-coronary dissection as a complication after heart catheterization using coronary computerized tomographic angiography Stefan Baumann, MD Aydin Huseynov, MD Michael Behnes, MD Daniel Frambach, MD,PhD Christian Böcker, MD Tobias Becher, MD Thomas Henzler, MD Ralf Lehmann, MD Martin Borggrefe, MD Ibrahim Akin, MD PII:
S0828-282X(14)00160-3
DOI:
10.1016/j.cjca.2014.03.014
Reference:
CJCA 1146
To appear in:
Canadian Journal of Cardiology
Received Date: 15 January 2014 Revised Date:
13 March 2014
Accepted Date: 13 March 2014
Please cite this article as: Baumann S, Huseynov A, Behnes M, Frambach D, Böcker C, Becher T, Henzler T, Lehmann R, Borggrefe M, Akin I, Treatment optimization of aorto-coronary dissection as a complication after heart catheterization using coronary computerized tomographic angiography, Canadian Journal of Cardiology (2014), doi: 10.1016/j.cjca.2014.03.014. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Treatment optimization of aorto-coronary dissection as a complication after heart catheterization using coronary computerized tomographic
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angiography
Stefan Baumann, MD¹*; Aydin Huseynov, MD¹*; Michael Behnes, MD¹; Daniel Frambach, MD,PhD¹; Christian Böcker, MD¹; Tobias Becher, MD¹; Thomas Henzler2, MD; Ralf Lehmann, MD¹;
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Martin Borggrefe, MD¹; Ibrahim Akin, MD¹
¹ First Department of Medicine, University Medical Centre Mannheim, University of Heidelberg, Mannheim, Germany.
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of Clinical Radiology, University Medical Center Mannheim , , University of Heidelberg, Mannheim Germany
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2 Department
Corresponding author: Stefan Baumann MD,
First Department of MedicineUniversity Medical Centre Mannheim (UMM)Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany.
aorto-coronary dissection ▪ ostial stenting ▪ Dual Source CT
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Keywords:
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: [email protected],: : +49 621 383 2204
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ACCEPTED MANUSCRIPT Brief summary The case presents a patient with a total occlusion of the right coronary artery (RCA) resulting as a complication of coronary intervention. Therapy consisted in stent implantation into the RCA. Computed tomography guided angiography revealed a progression of the intramural aortic haematoma with a dissection at the RCA ostium. Recurrent angiography was performed to implant another stent covering the entry.
Abstract
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We present the case of a 71-year-old patient with a chronic total occlusion of the RCA resulting in a retrograde aortic dissection as a complication of coronary intervention. Acute therapy consisted in coronary stent implantation into the proximal RCA to cover the dissection´s entry. One day after, CTA revealed a progression of the intramural aortic haematoma (IMH) with a residual dissection at the RCA ostium. Recurrent coronary angiography was performed to implant another stent
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covering the entry. Imaging at follow-up demonstrated complete coverage of the Dunning dissection and regression of IMH.
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ACCEPTED MANUSCRIPT Introduction Iatrogenic dissections of the coronary artery and ascending aorta during coronary angiography are uncommon but life threatening complications1.. Case Report This case deals with a 71-year-old patient presenting with chest pain (CCS class II) . Coronary artery
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disease was characterized by a chronic total occlusion (CTO) of the right coronary artery (RCA) (Fig. 1A).. After discussing the patient´s history decision was made to perform elective percutaneous coronary intervention (PCI) of the CTO lesion at the RCA. Revascularization was performed via an antegrade approach using a Miracle™ 6 wire (Asahi, Abbott Vascular, Illinois, USA), a Sapphire™
SC
1.0/10 mm balloon (Orbus Neich, Wanchai, Hong Kong) and rotablation with a 1.25 burr. (Fig. 1B). The culprit lesions at the RCA segment 1 and 2 were treated by two drug-eluting stents (Xience Pro 2.25/18
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and 2.25/15 mm; Abbott Vascular, Illinois, USA) and intracoronary abciximab application (Fig. 1C,D). Stent positioning before was difficult and only realizable by carefully pushing the Hockey-Stick™ guiding catheter (Boston Scientific, Natick, MA, USA) further into the RCA ostium. However, final control angiography revealed a dissection starting from the RCA ostium with retrograde extension into the aortic root of less than 40 mm (Dunning dissection class II) with concomitant impaired TIMI II flow in the RCA (Fig. 1E). Angiographically, the proximally implanted stent appeared to be placed closely to the true
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lumen of the aorta at the RCA ostium, presuming adequate coverage of the dissection´s entry (Fig. 1C,D). Therefore, only post-dilation by a non-compliant balloon (Quantum 2.5/15 mm) was finally performed.
One day after, computed tomography guided angiography (CTA) on a worldwide first installed prototype
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3rd generation Dual Source CT system (Somatom FORCE, Siemens,, Forchheim, Germany) revealed a distinct progression of the coronay dissection already reaching the brachiocephalic trunk, which now
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corresponds to a Dunning dissection class III (Fig. 2A). A thin non-covered dissection membrane at the RCA ostium (Fig. 2B) with retrograde blood flow into the false lumen of the ascending aorta was detected by CTA. Therefore, decision was made to perform repeat coronary angiography. Within the second PCI, another stent (Xience Pro 2.5/15 mm) was implanted at the RCA ostium extending into the true lumen of ascending aorta (Fig. 2C). Angiography and CTA during follow-up revealed a patent RCA without evidence of further entry (Fig. 1F).
Discussion Iatrogenic coronary dissections involving the ascending aorta are more common after PCI compared to diagnostic coronary angiography.. Carstensen et al. proposed rapid ostial coronary stenting as the 3
ACCEPTED MANUSCRIPT method of choice after detection of the aorto-coronary ostium associated with a good prognosis and long-term outcome2. Dunning et al.3 graduated three different classes of iatrogenic coronary artery dissections extending into and involving the ascendend aorta, which reveal different therapeutic strategies and outcomes. Class I and II dissections are recommended to be covered by tcoronary stenting, whereas serious outcomes
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with class III dissections have been described5. Therefore, class III dissection have been discussed to be preferably treated by cardiovascular surgery, because they involve cusps and extend up the aorta.. The use of an ultra high pitch CTA enabled to understand the pathomechanisms of disease progression, which was an incomplete sealing of the entry at the RCA ostium not seen on angiography. Excellent
SC
quality of images and speed make CTA a perfect method to follow up a propagation of aortic dissections.
It was demonstrated firstly, that this severe complication can both be reliably diagnosed and controlled
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by follow-high quality CTA to understand the underlying mechanisms, and, secondly, that even after deterioration of a Dunning dissection class II to a class III dissection, PCI with consecutive coronary stenting might represent an optimal therapeutic alternative. Additional information to angiography would be gained by use of intravascular ultrasound or optical coherence tomography, which would demonstrate the malapposition and lack of entry sealing. However, there would still remain a need for
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imaging during follow-up to evaluate the IMH..
Conclusion
In conclusionpatients may benefit from therapeutic stent placement although it might appear technically
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challenging depending on the degree of dissection and clinical condition.
4
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Figures
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Figure 1. CTO of the RCA (A) which was resulting in a TIMI-II flow (B). During position of stents (C, arrow), which were placed angiographically guided to the RCA ostium in segment 1 + 2 (D, arrow) a dissection of the RCA ostium extending retrogradely in the aorta ascendens occurred (Dunning type II) (E, arrow). No restenosis or residual dissection at follow-up angiography (F)
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Figure 2: CTA revealed an IMH (A, arrow). Initial stents were not placed close to the true aortic lumen (black arrow) but close to the false aortic lumen (white arrow) resulting in an uncovered entry (broken line) (B) which was responsible for the expansion of IMH. A further stent (white arrow) was placed to the RCA ostium extending a little bit in the true lumen of the aorta (black arrow) (C).
Disclosure Statement . None
5
ACCEPTED MANUSCRIPT References 1. Hunt I, Faircloth ME, Sinha P, Marber MS, Venn GE, Young CP. Aortocoronary dissection complicating angioplasty of chronically occluded right coronary arteries: is a conservative approach the right approach? The Journal of thoracic and cardiovascular surgery 2006;131:230-1. 2. Carstensen S, Ward MR. Iatrogenic aortocoronary dissection: the case for immediate aortoostial stenting. Heart, lung & circulation 2008;17:325-9.
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3. Dunning DW, Kahn JK, Hawkins ET, O'Neill WW. Iatrogenic coronary artery dissections extending into and involving the aortic root. Catheterization and cardiovascular interventions : official journal of the Society for Cardiac Angiography & Interventions 2000;51:387-93.
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ACCEPTED MANUSCRIPT
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ACCEPTED MANUSCRIPT
S0828-282X(14)00160-3
DOI:
10.1016/j.cjca.2014.03.014
Reference:
CJCA 1146
To appear in:
Canadian Journal of Cardiology
Received Date: 15 January 2014 Revised Date:
13 March 2014
Accepted Date: 13 March 2014
Please cite this article as: Baumann S, Huseynov A, Behnes M, Frambach D, Böcker C, Becher T, Henzler T, Lehmann R, Borggrefe M, Akin I, Treatment optimization of aorto-coronary dissection as a complication after heart catheterization using coronary computerized tomographic angiography, Canadian Journal of Cardiology (2014), doi: 10.1016/j.cjca.2014.03.014. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Treatment optimization of aorto-coronary dissection as a complication after heart catheterization using coronary computerized tomographic
RI PT
angiography
Stefan Baumann, MD¹*; Aydin Huseynov, MD¹*; Michael Behnes, MD¹; Daniel Frambach, MD,PhD¹; Christian Böcker, MD¹; Tobias Becher, MD¹; Thomas Henzler2, MD; Ralf Lehmann, MD¹;
SC
Martin Borggrefe, MD¹; Ibrahim Akin, MD¹
¹ First Department of Medicine, University Medical Centre Mannheim, University of Heidelberg, Mannheim, Germany.
M AN U
of Clinical Radiology, University Medical Center Mannheim , , University of Heidelberg, Mannheim Germany
TE D
2 Department
Corresponding author: Stefan Baumann MD,
First Department of MedicineUniversity Medical Centre Mannheim (UMM)Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany.
aorto-coronary dissection ▪ ostial stenting ▪ Dual Source CT
AC C
Keywords:
EP
: [email protected],: : +49 621 383 2204
1
ACCEPTED MANUSCRIPT Brief summary The case presents a patient with a total occlusion of the right coronary artery (RCA) resulting as a complication of coronary intervention. Therapy consisted in stent implantation into the RCA. Computed tomography guided angiography revealed a progression of the intramural aortic haematoma with a dissection at the RCA ostium. Recurrent angiography was performed to implant another stent covering the entry.
Abstract
RI PT
We present the case of a 71-year-old patient with a chronic total occlusion of the RCA resulting in a retrograde aortic dissection as a complication of coronary intervention. Acute therapy consisted in coronary stent implantation into the proximal RCA to cover the dissection´s entry. One day after, CTA revealed a progression of the intramural aortic haematoma (IMH) with a residual dissection at the RCA ostium. Recurrent coronary angiography was performed to implant another stent
AC C
EP
TE D
M AN U
SC
covering the entry. Imaging at follow-up demonstrated complete coverage of the Dunning dissection and regression of IMH.
2
ACCEPTED MANUSCRIPT Introduction Iatrogenic dissections of the coronary artery and ascending aorta during coronary angiography are uncommon but life threatening complications1.. Case Report This case deals with a 71-year-old patient presenting with chest pain (CCS class II) . Coronary artery
RI PT
disease was characterized by a chronic total occlusion (CTO) of the right coronary artery (RCA) (Fig. 1A).. After discussing the patient´s history decision was made to perform elective percutaneous coronary intervention (PCI) of the CTO lesion at the RCA. Revascularization was performed via an antegrade approach using a Miracle™ 6 wire (Asahi, Abbott Vascular, Illinois, USA), a Sapphire™
SC
1.0/10 mm balloon (Orbus Neich, Wanchai, Hong Kong) and rotablation with a 1.25 burr. (Fig. 1B). The culprit lesions at the RCA segment 1 and 2 were treated by two drug-eluting stents (Xience Pro 2.25/18
M AN U
and 2.25/15 mm; Abbott Vascular, Illinois, USA) and intracoronary abciximab application (Fig. 1C,D). Stent positioning before was difficult and only realizable by carefully pushing the Hockey-Stick™ guiding catheter (Boston Scientific, Natick, MA, USA) further into the RCA ostium. However, final control angiography revealed a dissection starting from the RCA ostium with retrograde extension into the aortic root of less than 40 mm (Dunning dissection class II) with concomitant impaired TIMI II flow in the RCA (Fig. 1E). Angiographically, the proximally implanted stent appeared to be placed closely to the true
TE D
lumen of the aorta at the RCA ostium, presuming adequate coverage of the dissection´s entry (Fig. 1C,D). Therefore, only post-dilation by a non-compliant balloon (Quantum 2.5/15 mm) was finally performed.
One day after, computed tomography guided angiography (CTA) on a worldwide first installed prototype
EP
3rd generation Dual Source CT system (Somatom FORCE, Siemens,, Forchheim, Germany) revealed a distinct progression of the coronay dissection already reaching the brachiocephalic trunk, which now
AC C
corresponds to a Dunning dissection class III (Fig. 2A). A thin non-covered dissection membrane at the RCA ostium (Fig. 2B) with retrograde blood flow into the false lumen of the ascending aorta was detected by CTA. Therefore, decision was made to perform repeat coronary angiography. Within the second PCI, another stent (Xience Pro 2.5/15 mm) was implanted at the RCA ostium extending into the true lumen of ascending aorta (Fig. 2C). Angiography and CTA during follow-up revealed a patent RCA without evidence of further entry (Fig. 1F).
Discussion Iatrogenic coronary dissections involving the ascending aorta are more common after PCI compared to diagnostic coronary angiography.. Carstensen et al. proposed rapid ostial coronary stenting as the 3
ACCEPTED MANUSCRIPT method of choice after detection of the aorto-coronary ostium associated with a good prognosis and long-term outcome2. Dunning et al.3 graduated three different classes of iatrogenic coronary artery dissections extending into and involving the ascendend aorta, which reveal different therapeutic strategies and outcomes. Class I and II dissections are recommended to be covered by tcoronary stenting, whereas serious outcomes
RI PT
with class III dissections have been described5. Therefore, class III dissection have been discussed to be preferably treated by cardiovascular surgery, because they involve cusps and extend up the aorta.. The use of an ultra high pitch CTA enabled to understand the pathomechanisms of disease progression, which was an incomplete sealing of the entry at the RCA ostium not seen on angiography. Excellent
SC
quality of images and speed make CTA a perfect method to follow up a propagation of aortic dissections.
It was demonstrated firstly, that this severe complication can both be reliably diagnosed and controlled
M AN U
by follow-high quality CTA to understand the underlying mechanisms, and, secondly, that even after deterioration of a Dunning dissection class II to a class III dissection, PCI with consecutive coronary stenting might represent an optimal therapeutic alternative. Additional information to angiography would be gained by use of intravascular ultrasound or optical coherence tomography, which would demonstrate the malapposition and lack of entry sealing. However, there would still remain a need for
TE D
imaging during follow-up to evaluate the IMH..
Conclusion
In conclusionpatients may benefit from therapeutic stent placement although it might appear technically
AC C
EP
challenging depending on the degree of dissection and clinical condition.
4
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SC
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Figures
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Figure 1. CTO of the RCA (A) which was resulting in a TIMI-II flow (B). During position of stents (C, arrow), which were placed angiographically guided to the RCA ostium in segment 1 + 2 (D, arrow) a dissection of the RCA ostium extending retrogradely in the aorta ascendens occurred (Dunning type II) (E, arrow). No restenosis or residual dissection at follow-up angiography (F)
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Figure 2: CTA revealed an IMH (A, arrow). Initial stents were not placed close to the true aortic lumen (black arrow) but close to the false aortic lumen (white arrow) resulting in an uncovered entry (broken line) (B) which was responsible for the expansion of IMH. A further stent (white arrow) was placed to the RCA ostium extending a little bit in the true lumen of the aorta (black arrow) (C).
Disclosure Statement . None
5
ACCEPTED MANUSCRIPT References 1. Hunt I, Faircloth ME, Sinha P, Marber MS, Venn GE, Young CP. Aortocoronary dissection complicating angioplasty of chronically occluded right coronary arteries: is a conservative approach the right approach? The Journal of thoracic and cardiovascular surgery 2006;131:230-1. 2. Carstensen S, Ward MR. Iatrogenic aortocoronary dissection: the case for immediate aortoostial stenting. Heart, lung & circulation 2008;17:325-9.
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M AN U
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3. Dunning DW, Kahn JK, Hawkins ET, O'Neill WW. Iatrogenic coronary artery dissections extending into and involving the aortic root. Catheterization and cardiovascular interventions : official journal of the Society for Cardiac Angiography & Interventions 2000;51:387-93.
6
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ACCEPTED MANUSCRIPT
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