Iatrogenic Aortic Dissection Complicating Percutaneous Coronary Intervention for Chronic Total Occlusion

Percutaneous Management of Iatrogenic Aortocoronary Dissection Complicating Diagnostic Angiography or Percutaneous Coronary Intervention

“…The incidence of this complication was approximately 0.02% for diagnostic coronary angiography and 0.02-0.83% for PCI procedures. 2 - 5 The rapid propagation of aortocoronary dissection may become immediately life threatening via several mechanisms, including hemorrhage into the pericardium resulting in cardiac tamponade, occlusion of the contralateral coronary ostium, or propagation of the dissection into the descending aorta. 6 , 7 Most reported iatrogenic aortocoronary dissections have been related to procedures in the RCA, especially during PCI for chronic total occlusions.…”

“… 6 , 7 Most reported iatrogenic aortocoronary dissections have been related to procedures in the RCA, especially during PCI for chronic total occlusions. 2 The RCA is more easily dissected retrogradely into the coronary sinus than the left main coronary artery (LMCA). This may be because the periostial wall and sinotubular junction of the LMCA are formed by more smooth muscle cells and by a dense matrix of collagen type I fibers 8 .…”

“…Additionally, the surgical repair of catheter-related dissection may be more risky in the setting of coronary ischemia and following PCI with full anticoagulation and antiplatelet therapy. Boukhris et al 2 recently assessed the management strategy and outcomes of such a complication among 956 cases of complicating PCI for chronic total occlusion, and found aortocoronary dissection occurred in eight patients for an overall frequency of 0.83%. In all these cases, rapid ostial stenting was performed and no emergency surgery was required.…”

“…Aortocoronary dissection is an infrequent, yet potentially catastrophic complication of coronary angiography (CAG) or percutaneous coronary intervention (PCI) that can lead to emergency surgical aortic repair, coronary artery bypass graft surgery (CABG) or death. 1 , 2 According to the extent of aortic root involvement, Dunning et al. 3 proposed three classes of aortocoronary dissection: Class I for focal dissection limited to the sinus of Valsalva; Class II for dissection that propagated less than 40 mm to the ascending aorta; and Class III for dissection extending 40 mm or more to the ascending aorta.…”

Anchor balloons assisted deep intubation of 5F catheters for uncrossable lesions

“…(2) Although there was no vessel dissection from deeper insertion of the "child" catheter in the four reported cases, operators should gently manipulate the "child" catheter while it is deeply inserted into the coronary artery to avoid damaging the vessel wall which could even result in aortic dissection. [12] Besides, the contrast injection should be gently performed. (3) The balloon should be placed at the lesion segment while anchoring the entire system to avoid damaging the normal segment of the coronary artery.…”