Stent-supported angioplasty of a residual coronary artery dissection following replacement of the ascending aorta for acute type A aortic di
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《血管的通路杂志》
Department of Thoracic and Cardiovascular Surgery, Osaka Mishima Emergency and Critical Care Medical Center, 11-1 Minami Akutagawa-cho, Takatsuki City, Osaka 569-1124, Japan
Abstract
The patient was a 54-year-old male who suddenly noted severe back pain while eating. A diagnosis of acute type A aortic dissection was made on contrast enhanced CT. As a result, emergency surgical repair was performed on the same day. Through median sternotomy, graft replacement of the ascending aorta, including removal of the site of the intimal tear, was carried out under deep hypothermia and retrograde cerebral perfusion. Although the postoperative course was satisfactory, the patient complained of severe chest pain with ECG change on the 23rd postoperative day. Emergency coronary angiography revealed the presence of wide coronary artery dissection from an entry of the left anterior descending aorta (LAD) to a reentry of the left circumflex artery (LCX). Multiple stents were implanted in the LAD and LCX. After stenting, chest symptoms were relieved, and ECG change disappeared. He was discharged from our hospital on the 42nd postoperative day.
Key Words: Ascending aortic dissection; Coronary artery dissection; Angioplasty
1. Introduction
Acute type A aortic dissection continues to be a condition associated with significant risk for early death. If this condition is unrecognized and untreated, the related mortality is high during the first 48 h. Therefore, early operative intervention with graft replacement of the ascending aorta, including removal of the site of the intimal tear, has become a widely accepted method of treatment [1–3]. Generally, the approach to coronary revascularization for the patients with acute dissection of coronary arteries was reported [4, 5].
We report a rare case, which was successfully treated by stent-supported angioplasty, of a residual coronary artery dissection following replacement of the ascending aorta.
2. Case report
The patient was a 54-year-old male who suddenly noted severe back pain while eating. Initially, the patient was transferred to another hospital, and then referred to our center based on a diagnosis of acute myocardial infarction (AMI). Although myocardial ischemia was suspected by the initial ECG finding, laterality of blood pressure was observed in the bilateral radial arteries. Contrast enhanced CT was performed immediately. As a result, acute type A aortic dissection (the extension of dissection from the ascending aorta to the bilateral common iliac artery) was detected and emergency surgical repair was performed on the same day. The operation was performed through a median sternotomy using femoral vein and superior vene caval cannulation and femoral arterial pump return. The repair was performed by an open distal technique under hypothermic circulatory arrest and retrograde cerebral perfusion. The tear was presented on the ascending aorta, and the proximal side of the false lumen extended to the bilateral coronary orifice. However, the coronary arterial orifice was intact. Therefore, it was judged that further progression of dissection of the aortic root could be prevented by removal of the site of the intimal tear and closing the false lumen. After closing the false lumen with Gelatin-Resorcin-Formalin (GRF) glue and sandwiching the two aortic wall layers between Teflon felt strips, we performed graft replacement of the ascending aorta including removal of the site of the intimal tear by a 24-mm Dacron graft. The patient was weaned from cardiopulmonary bypass without difficulty.
Although the postoperative course was satisfactory, suddenly, the patient complained of severe chest pain on the 23rd postoperative day. ECG showed significant ST-segment depression in leads V3, V4, V5, and V6. Emergency coronary angiography was performed and revealed the presence of residual coronary arterial dissection in the left anterior descending artery (LAD) and the left circumflex artery (LCX). The LCX was severely compressed by the false lumen (Fig. 1A). Through the false lumen, the blood flowed inversely from the original reentry on the LAD toward the left main trunk (LMT), and then returned by the true lumen through the original reentry in the LCX (Fig. 1B). The blood did not flow into the left main trunk by the graft replacement including removal of the intimal tear. Therefore, to eliminate blood flow through the false lumen, the patient underwent implantation of multiple Elite stents (Boston Scientific, Natick, Massachusetts) in the LAD and the LCX with standard techniques. After stenting, the coronary blood flow was improved (Fig. 2A). His chest symptoms were relieved, and ECG change disappeared. Thereafter, he did not complain of chest symptoms, and also coronary angiography performed 2 weeks later demonstrated favorable blood flow in the true lumen. He was discharged from our hospital on the 42nd postoperative day.
3. Discussion
Acute type A aortic dissection, especially in the acute phase, may result in sudden death for its various clinical presentations. The formation of the false lumen may lead to death by free rupture through the thin outer wall into the pericardial or pleural space and the shearing off of the coronary arteries from their sinuses of Valsalva. Generally, the incidence of coronary artery dissection has been reported as 8% in the right coronary artery, and 11% in the left coronary artery [6]. Myocardial infarction occurs in 1–2% of patients with dissection of the ascending aorta, because of compression of the coronary ostium by hematoma or occlusion by intimal flap.
No previous studies have reported recanalization of the coronary artery for myocardial ischemia caused by residual coronary arterial dissection during the chronic postoperative stage. We hypothesized the following developmentalmechanism in our patient. That is, coronary arterial dissection retrogradely developing from the aortic entry extended to the LAD and LCX beyond the left main trunk, which probably resulted in the formation of reentries respectively in the periphery of the LAD and LCX (Fig. 2B). Although the false lumen proximal to the left main trunk was successfully closed by graft replacement of the ascending aorta, including the entry, this procedure made the reentry in the LAD a new entry, which probably resulted in the formation of another false lumen extending to the LCX. When the false lumen in the LAD was dilated by compression with a perfusion catheter, coronary arteriographic findings suggested marked improvement of blood flow through the true lumen of the LCX.
Coronary arterial dissection without reentry may not cause myocardial ischemia during the acute postoperative stage. This is because the residual dissecting lumen in the coronary artery becomes a cecum if there is no reentry, and the false lumen will be closed during the chronic stage when the graft replacement is performed at least in the ascending aorta, including the entry, although surgical techniques for acute type A aortic dissection vary depending on the extent of dissection and location of the entry. If there is only one reentry, most of the false lumen will be closed during the chronic stage because the entry in the coronary artery becomes the cecum. Even when the dissecting lumen remains, it is not likely to cause myocardial ischemia because the blood flows reversely through the false lumen of the coronary artery. Since our patient had several reentries in the coronary artery, he might have been caused myocardial ischemia.
Consequently, PTCA was successfully performed in our patient. However, careful follow-up is required hereafter.
References
Lindsay J Jr, Hurst JW. Clinical features and prognosis in dissecting aneurysm of the aorta. A re-appraisal. Circulation 1967;35:880–888.
Jamieson WR, Munro AI, Miyagishima RT, Allen P, Tyers GF, Gerein AN. Aortic dissection: early diagnosis and surgical management are the keys to survival. Can J Surg 1982;25:145–149.
McCloy RM, Spittel JA Jr, McGoon DC. The prognosis in aortic dissection (dissecting aortic hematoma or aneurysm). Circulation 1965;31:665–669.
DeBakey ME, McCollum CH, Crawford ES, Morris GC Jr, Howell J, Noon GP, Lawrie G. Dissection and dissecting aneurysms of the aorta: twenty-year follow-up of five hundred twenty-seven patients treated surgically. Surgery 1982;92:1118–1134.
Miller DC, Stinson EB, Oyer PE, Rossiter SJ, Reitz BA, Griepp RB, Shumway NE. Operative treatment of aortic dissections. Experience with 125 patients over a sixteen-year period. J Thorac Cardiovasc Surg 1979;78:365–382.
Hirst AE, Johns VJ, Kime SW. Dissecting aneurysm of the aorta: a review of 505 cases. Medicine 1958;37:217–279.(Masayoshi Nishimoto, Hiro)
Abstract
The patient was a 54-year-old male who suddenly noted severe back pain while eating. A diagnosis of acute type A aortic dissection was made on contrast enhanced CT. As a result, emergency surgical repair was performed on the same day. Through median sternotomy, graft replacement of the ascending aorta, including removal of the site of the intimal tear, was carried out under deep hypothermia and retrograde cerebral perfusion. Although the postoperative course was satisfactory, the patient complained of severe chest pain with ECG change on the 23rd postoperative day. Emergency coronary angiography revealed the presence of wide coronary artery dissection from an entry of the left anterior descending aorta (LAD) to a reentry of the left circumflex artery (LCX). Multiple stents were implanted in the LAD and LCX. After stenting, chest symptoms were relieved, and ECG change disappeared. He was discharged from our hospital on the 42nd postoperative day.
Key Words: Ascending aortic dissection; Coronary artery dissection; Angioplasty
1. Introduction
Acute type A aortic dissection continues to be a condition associated with significant risk for early death. If this condition is unrecognized and untreated, the related mortality is high during the first 48 h. Therefore, early operative intervention with graft replacement of the ascending aorta, including removal of the site of the intimal tear, has become a widely accepted method of treatment [1–3]. Generally, the approach to coronary revascularization for the patients with acute dissection of coronary arteries was reported [4, 5].
We report a rare case, which was successfully treated by stent-supported angioplasty, of a residual coronary artery dissection following replacement of the ascending aorta.
2. Case report
The patient was a 54-year-old male who suddenly noted severe back pain while eating. Initially, the patient was transferred to another hospital, and then referred to our center based on a diagnosis of acute myocardial infarction (AMI). Although myocardial ischemia was suspected by the initial ECG finding, laterality of blood pressure was observed in the bilateral radial arteries. Contrast enhanced CT was performed immediately. As a result, acute type A aortic dissection (the extension of dissection from the ascending aorta to the bilateral common iliac artery) was detected and emergency surgical repair was performed on the same day. The operation was performed through a median sternotomy using femoral vein and superior vene caval cannulation and femoral arterial pump return. The repair was performed by an open distal technique under hypothermic circulatory arrest and retrograde cerebral perfusion. The tear was presented on the ascending aorta, and the proximal side of the false lumen extended to the bilateral coronary orifice. However, the coronary arterial orifice was intact. Therefore, it was judged that further progression of dissection of the aortic root could be prevented by removal of the site of the intimal tear and closing the false lumen. After closing the false lumen with Gelatin-Resorcin-Formalin (GRF) glue and sandwiching the two aortic wall layers between Teflon felt strips, we performed graft replacement of the ascending aorta including removal of the site of the intimal tear by a 24-mm Dacron graft. The patient was weaned from cardiopulmonary bypass without difficulty.
Although the postoperative course was satisfactory, suddenly, the patient complained of severe chest pain on the 23rd postoperative day. ECG showed significant ST-segment depression in leads V3, V4, V5, and V6. Emergency coronary angiography was performed and revealed the presence of residual coronary arterial dissection in the left anterior descending artery (LAD) and the left circumflex artery (LCX). The LCX was severely compressed by the false lumen (Fig. 1A). Through the false lumen, the blood flowed inversely from the original reentry on the LAD toward the left main trunk (LMT), and then returned by the true lumen through the original reentry in the LCX (Fig. 1B). The blood did not flow into the left main trunk by the graft replacement including removal of the intimal tear. Therefore, to eliminate blood flow through the false lumen, the patient underwent implantation of multiple Elite stents (Boston Scientific, Natick, Massachusetts) in the LAD and the LCX with standard techniques. After stenting, the coronary blood flow was improved (Fig. 2A). His chest symptoms were relieved, and ECG change disappeared. Thereafter, he did not complain of chest symptoms, and also coronary angiography performed 2 weeks later demonstrated favorable blood flow in the true lumen. He was discharged from our hospital on the 42nd postoperative day.
3. Discussion
Acute type A aortic dissection, especially in the acute phase, may result in sudden death for its various clinical presentations. The formation of the false lumen may lead to death by free rupture through the thin outer wall into the pericardial or pleural space and the shearing off of the coronary arteries from their sinuses of Valsalva. Generally, the incidence of coronary artery dissection has been reported as 8% in the right coronary artery, and 11% in the left coronary artery [6]. Myocardial infarction occurs in 1–2% of patients with dissection of the ascending aorta, because of compression of the coronary ostium by hematoma or occlusion by intimal flap.
No previous studies have reported recanalization of the coronary artery for myocardial ischemia caused by residual coronary arterial dissection during the chronic postoperative stage. We hypothesized the following developmentalmechanism in our patient. That is, coronary arterial dissection retrogradely developing from the aortic entry extended to the LAD and LCX beyond the left main trunk, which probably resulted in the formation of reentries respectively in the periphery of the LAD and LCX (Fig. 2B). Although the false lumen proximal to the left main trunk was successfully closed by graft replacement of the ascending aorta, including the entry, this procedure made the reentry in the LAD a new entry, which probably resulted in the formation of another false lumen extending to the LCX. When the false lumen in the LAD was dilated by compression with a perfusion catheter, coronary arteriographic findings suggested marked improvement of blood flow through the true lumen of the LCX.
Coronary arterial dissection without reentry may not cause myocardial ischemia during the acute postoperative stage. This is because the residual dissecting lumen in the coronary artery becomes a cecum if there is no reentry, and the false lumen will be closed during the chronic stage when the graft replacement is performed at least in the ascending aorta, including the entry, although surgical techniques for acute type A aortic dissection vary depending on the extent of dissection and location of the entry. If there is only one reentry, most of the false lumen will be closed during the chronic stage because the entry in the coronary artery becomes the cecum. Even when the dissecting lumen remains, it is not likely to cause myocardial ischemia because the blood flows reversely through the false lumen of the coronary artery. Since our patient had several reentries in the coronary artery, he might have been caused myocardial ischemia.
Consequently, PTCA was successfully performed in our patient. However, careful follow-up is required hereafter.
References
Lindsay J Jr, Hurst JW. Clinical features and prognosis in dissecting aneurysm of the aorta. A re-appraisal. Circulation 1967;35:880–888.
Jamieson WR, Munro AI, Miyagishima RT, Allen P, Tyers GF, Gerein AN. Aortic dissection: early diagnosis and surgical management are the keys to survival. Can J Surg 1982;25:145–149.
McCloy RM, Spittel JA Jr, McGoon DC. The prognosis in aortic dissection (dissecting aortic hematoma or aneurysm). Circulation 1965;31:665–669.
DeBakey ME, McCollum CH, Crawford ES, Morris GC Jr, Howell J, Noon GP, Lawrie G. Dissection and dissecting aneurysms of the aorta: twenty-year follow-up of five hundred twenty-seven patients treated surgically. Surgery 1982;92:1118–1134.
Miller DC, Stinson EB, Oyer PE, Rossiter SJ, Reitz BA, Griepp RB, Shumway NE. Operative treatment of aortic dissections. Experience with 125 patients over a sixteen-year period. J Thorac Cardiovasc Surg 1979;78:365–382.
Hirst AE, Johns VJ, Kime SW. Dissecting aneurysm of the aorta: a review of 505 cases. Medicine 1958;37:217–279.(Masayoshi Nishimoto, Hiro)