A 73-year-old male patient with history of hypertension and tobacco use presented to the emergency department after a syncopal episode. Syncope was preceded by chest pain, nausea, and cutaneous pallor approximately 24 hours prior to presentation. Initial electrocardiogram showed sinus rhythm, with ST-segment depression in V2 to V6, II, III and aVF. Initial cardiac troponin I and CK-MB were moderately elevated.
The patient was hemodynamically stable in Killip class 1. Symptoms improved after administration of aspirin, ticagrelor, enoxaparin, and intravenous nitroglycerin.
Transthoracic echocardiography was significant for left ventricular ejection fraction of 59%, hypokinesis of the basal segment of the inferior wall, and mild dilatation of the ascending aorta. Diagnostic cardiac catheterization showed severe stenoses in the proximal, middle, and distal right coronary artery (RCA) (Video 1). Nonobstructive lesions were seen in the left anterior descending and left circumflex arteries (Videos 2-3). Engagement of the right coronary ostium was challenging due extreme tortuosity in the iliac arteries. After the last RCA injection, TIMI 0 flow was noted (Video 4). The patient remained stable, without chest pain or neurological symptoms.
Video 1
Video 2
Video 3
Video 4
Considering this complication, what would be the best approach?
Show Answer
The correct answer is: C. Percutaneous recanalization of the RCA with ostial stenting followed by further imaging of the aorta with transesophageal echocardiography or computed tomography.
Given the flow restriction in the RCA, we chose to attempt immediate percutaneous revascularization of the occluded vessel. A bare-metal stent was implanted in the ostium extending into the coronary sinus. A second stent was then deployed in the distal vessel. TIMI 3 flow was obtained at the end of the intervention (Video 5). During the procedure, the patient remained hemodynamically stable, asymptomatic, and without neurological or electrocardiographic changes.
Video 5
Although the coronary dissection appeared to be sealed after stenting, aortography showed an extensive dissection of the aortic root, extending to the ascending aorta (Video 6). Urgent transesophageal echocardiogram performed in the catheterization laboratory showed mild ectasia of the ascending aorta with a type A aortic dissection and mild intimal separation up to the proximal ascending aorta. A small pericardial effusion was also noted.
Video 6
After discussion with the heart team, we decided to continue medical treatment without surgical intervention for the aortic dissection. The patient had an uneventful clinical course without recurrence of chest pain or other clinical signs of aortic dissection. The second transesophageal echocardiogram performed 24 hours after coronary intervention showed no progression of the sub-intimal hematoma. Follow-up echocardiography performed prior to hospital discharge showed complete healing of the aortic dissection.
Retrograde dissection of the aorta is a rare but potentially life-threatening complication of percutaneous procedures and may begin in the aortic root or coronary ostium. It may be caused by direct damage (catheter or guidewire), contrast injection, or underlying vascular degeneration. When it involves the sinus of Valsalva, the risk of severe complications is increased. When this angiographic finding is observed, forceful injection of contrast medium should be avoided.1,2
Some authors suggest that even when the initial clinical presentation is benign, progression of the dissection into the ascending aorta and cervical vessels may suddenly develop. In published series of right coronary sinus dissections, some of them complicated by ascending aortic dissections, several different approaches have been proposed. In the pre-stent era, conservative treatment used to be favored for dissections that remained relatively localized and in the absence of life-threatening conditions such as severe aortic regurgitation, hemopericardium, unstable hemodynamics, intractable chest pain, guidewire failing to cross the occluded lesion, and left main retrograde dissection.
In the stent era, covering the RCA ostium seems to be the best immediate approach; in some reports, the dissections were successfully treated with stents and no further complications were noted. Even in the presence of complications, coronary ostium stenting seem to stabilize the dissection and serve as a bridge to surgery.2,3 The ostial stent may break down the dissection route and prevent further propagation into the ascending aorta, avoiding the need for surgical interventions. Dissections >20 mm are at higher risk of complications and should be closely monitored after intervention. Transesophageal echocardiography is suggested to be a safe and useful tool,4 being equal or even superior to computed tomography scanning or aortography in recognizing the eventual progression of the dissection.
References
Yip HK, Wu CJ, Yeh KH, et al. Unusual complication of retrograde dissection to the coronary sinus of valsalva during percutaneous revascularization: a single-center experience and literature review. Chest 2001;119:493-501.
Li L, Cao Y. Extensive dissection to the coronary sinus of valsalva during percutaneous intervention in right coronary artery-a case report and literature review. Clin Med Insights Cardiol 2011;5:41-4.
Sekiguchi M, Sagawa N, Miyajima A, Hasegawa S, Yamazaki M, Kurabayashi M. Simultaneous right and left coronary occlusion caused by an extensive dissection to the coronary sinus of Valsalva during percutaneous intervention in right coronary artery. Int Heart J 2009;50:663-7.
Varma V, Nanda NC, Soto B, et al. Transesophageal echocardiographic demonstration of proximal right coronary artery dissection extending into the aortic root. Am Heart J 1992;123:1055-7.
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