Spontaneous coronary artery dissection and associated CT coronary angiographic findings: a case report and review

We report a case of an acute coronary syndrome in a 21-year-old male with invasive coronary angiography and computed tomography (CT) coronary angiography showing a spontaneous dissection of the left anterior descending artery. To our knowledge the CT coronary angiographic appearance of spontaneous coronary artery dissection has been reported only once before. We describe the role CT coronary angiography may have in the evaluation of coronary dissection as well as potential treatment options.     

合并主动脉夹层的冠心病患者联合冠状动脉介入治疗的临床分析

目的评价合并主动脉夹层的冠心病患者联合进行覆膜支架及冠状动脉介入治疗的安全性和有效性。方法选择合并主动脉夹层的冠心病患者共12例,已行外科治疗Ⅰ型主动脉夹层1例,大血管CT血管成像明确诊断Ⅲ型主动脉夹层和壁间血肿11例,冠状动脉造影并置入支架,住院观察,并行院外随访。结果 1例Ⅰ型主动脉夹层患者大血管CT血管成像可见覆膜支架、人工血管形态正常,冠状动脉造影显示,3支血管病变,共置入支架3枚;另11例Ⅲ型主动脉夹层和壁间血肿患者行大动脉覆膜支架治疗,大动脉造影显示,破口封闭,冠状动脉造影显示,16支血管病变,共置入支架18枚。其中1例术后仍有胸背部疼痛,大血管CT血管成像显示,主动脉弓降部可见残存破口,真腔明显受压,再次置入微创覆膜支架后症状缓解出院,住院及随访期间无胸痛再发、死亡、肾功能恶化、偏瘫等。结论对同时合并主动脉夹层的冠心病患者进行联合介入治疗安全性好,术后恢复快。     

Collateral blood flow showing dissection-like filling defect on coronary arteriography: a case report]

A 51-year-old man presented under a diagnosis of angina pectoris manifesting as exertional chest pain. First coronary angiography showed severe stenosis with ulceration and spontaneous dissection at the proximal right coronary artery and linear dissection-like filling defects extending to the distal right coronary artery. After about 3 months, repeat coronary angiography showed the previously observed stenosis with unclear dissection, and better developed collaterals from the left coronary artery to the right coronary artery showing the linear dissection-like filling defects. The bilateral coronary angiography did not clearly show filling defects. This phenomenon suggested that the collateral flows were related to filling of the defects. Intravascular ultrasonic imaging demonstrated severe atherosclerotic lesions at the proximal right coronary artery, but no dissection in the distal right coronary artery. Percutaneous transluminal coronary angioplasty for the stenosis was performed successfully with a stent. Coronary angiography after the angioplasty showed no collaterals, and the right ventricular branch appeared, suggesting that the linear dissection-like filling defects extending to the distal right coronary artery were due to the collateral flows. Filling defects extending distal to a severe stenosis must be distinguished carefully from coronary dissection.     

Combined dissection of the right coronary artery and right coronary cusp during coronary angiography

Dissection of coronary arteries during diagnostic coronary angiography is infrequent; dissection of the coronary cusp is extremely rare. The combination of coronary artery and coronary cusp dissection has not been reported previously. A case of right coronary artery dissection and right coronary cusp dissection during diagnostic coronary angiography is described. © 1995 Wiley-Liss, Inc.     

Left main coronary artery dissection during cardiac catheterization.

A 70-year-old man with a downward sloping origin of the left main coronary artery developed left main dissection at coronary angiography and died despite emergency coronary by-pass surgery. Autopsy showed that the left main coronary artery had an acute angle take off and dissection had originated at the junction of the superior wall of the left main and the aorta. The combination of left main stenosis secondary to dissection and severe right coronary atherosclerosis had caused circumferential subendocardial left ventricular infarction. The left main coronary artery had mild atherosclerosis and lacked cystic medial necrosis. An angulated left main coronary artery may be a risk factor for dissection at angiography.     

Emergency stenting of unprotected left main coronary artery after acute catheter-induced occlusive dissection

Left main coronary artery dissection occurs very rarely during selective coronary angiography, but it generally progresses to complete coronary occlusion. The traditional treatment of occlusive dissection of the unprotected left main coronary artery has been surgical. Percutaneous treatment has been sporadic and controversial. We report a case of iatrogenic occlusive dissection of the unprotected left main coronary artery during diagnostic coronary angiography, followed by successful stenting of the lesion.     

Coronary artery dissection after blunt chest trauma: subacute and chronic phase assessment by intravascular ultrasonography: a case report

A 35-year-old man sustained a steering wheel injury in a motor vehicle accident. Initial electrocardiography showed ST-segment elevation. Coronary angiography revealed a dissection of the right coronary artery and perfusion delay in the left anterior descending artery. Coronary stents were inserted into the left anterior descending artery. One month later, coronary angiography and intravascular ultrasonography showed that the dissection of the right coronary artery was still present. Coronary stents were inserted from the aorto-ostial lesion to the mid portion of the right coronary artery. Six months later, coronary angiography and intravascular ultrasonography revealed diffuse neointimal hyperplasia inside all of the stents, and the aorto-ostial stent had severe stenosis with perfusion delay. Severe neointimal hyperplasia was found inside the stents used for repair of the coronary artery dissection.     

Treatment Optimization of Aortocoronary Dissection as a Complication After Heart Catheterization Using Coronary Computerized Tomographic Angiography

We present the case of a 71-year-old patient with a chronic total occlusion of the right coronary artery (RCA) resulting in a retrograde aortic dissection as a complication of coronary intervention. Acute therapy consisted of coronary stent implantation into the proximal RCA to cover the dissection's entry. One day after, computed tomography-guided angiography revealed a progression of the intramural aortic hematoma with a residual dissection at the RCA ostium. Recurrent coronary angiography was performed to implant another stent covering the entry. Imaging at follow-up demonstrated complete coverage of the Dunning dissection and regression of the intramural aortic hematoma.     

Diagnostic efficacy of coronary CT angiography as a follow-up modality for procedure-related coronary dissection

Procedure-related coronary dissection is associated with an increased risk of major adverse cardiovascular events after percutaneous coronary intervention (PCI). In most patients with such an iatrogenic complication, further PCI or bypass surgery aimed at complete revascularization is performed. Moreover, conventional coronary angiography has been used as a standard modality in the follow-up of such patients. The present report describes a 70 year old female patient who was complicated by catheter-related extensive coronary dissection in the right coronary artery (RCA) when treated for an acute myocardial infarction. Although RCA flow was insufficient, we decided against revascularization and followed her medically without additional revascularization procedures. Her clinical course had been uneventful for 4 years. However, symptoms of effort angina developed and re-examinations were performed at approximately 5 years after the myocardial infarction. Although conventional coronary angiography failed to show the culprit lesion responsible for the angina symptoms, the superior spatial resolution of the coronary CT angiography clearly identified significant progression of the stenotic lesion in the true lumen of the dissected RCA. Thus, coronary CT angiography might be considered as a possible first-line follow-up modality in patients with procedure-related coronary dissection.     

Coronary artery dissection following angioplasty evaluated by fractional flow reserve: report of three cases]

Fractional flow reserve was measured in three patients with coronary artery dissection occurring after percutaneous coronary intervention. In Case 1, fractional flow reserve decreased from 0.88 to 0.73 and angiography showed coronary artery dissection 20 min after balloon angioplasty. In Case 2, angiography showed good results, but the fractional flow reserve decreased to a low value(0.69). Intravascular ultrasonography revealed dissection. In Case 3, angiography clearly showed dissection, but fractional flow reserve remained high(0.91). Stent implantation was performed in all three patients, but might not have been necessary in Case 3. Dissection with low or diminished fractional flow reserve value may cause a pressure gradient in the true lumen. Stent implantation is necessary in such cases. On the other hand, cases of dissection in which the fractional flow reserve value is maintained may also cause a pressure gradient in true lumen, but stent implantation may not be necessary. Fractional flow reserve measurements may be useful for the assessment of coronary artery dissection and evaluating the indications for stent implantation.     

Diagnosis and treatment of concomitant aortic and coronary disease: a retrospective study and brief review.

Coronary arteriosclerosis seriously complicates the surgical treatment of aortic diseases. The aim of our retrospective study was to determine the incidence of coronary artery disease among our surgical patients in treatment for aortic dissection or aneurysm, and to determine whether coronary intervention before aortic surgery appears to affect outcomes. Between 1 January 1993 and 1 March 1998, our center treated 253 patients for aortic dissection or aneurysm. We examined these cases retrospectively for information on diagnostic and treatment methods, both for the aortic lesions and for concomitant coronary arteriosclerosis. Aortic dissection had been detected in 86 (33.9%) patients and aortic aneurysm in 167 (66.1%). Coronary angiography was performed to search for concomitant coronary artery disease in 29 (33.8%) patients with dissection and in 112 (67.1%) patients with aneurysm; of these, 11 (12. 7%) and 54 (32.3%), respectively, were found to have coronary disease. Among 43 patients with abdominal aortic aneurysm in whom coronary angiography was performed, concomitant coronary disease was detected in 36 (83.7%). Coronary artery bypass surgery was performed in 10 patients who had dissection and in 30 patients who had aneurysm; percutaneous transluminal coronary angioplasty was performed in 7 patients who had aneurysm. Perioperative mortality rates in the dissection and aneurysm groups, overall, were 23.2% and 13.8%, respectively Unfortunately, the prospective, random clinical study that would be necessary to prove the case for or against preoperative coronary angiography among subsets of patients in need of aortic repair would raise ethical questions, given the strength of the information already in our possession, gathered by less formal methods. Our study reinforces existing evidence that preoperative angiography can reduce mortality and morbidity in the elective repair of aortic aneurysm, especially thoracic or abdominal aneurysm. However, angiography should not be performed routinely in cases of aortic dissection and should be withheld in cases of type A dissection.     

Successful stenting of catheter-induced unprotected left main coronary artery dissection

Catheter-induced left main coronary artery (LMCA) dissection is a dramatic, although uncommon complication of diagnostic coronary angiography and requires prompt treatment. We describe a case of iatrogenic occlusive dissection of the LMCA during coronary angiography, treated by subsequent percutaneous recanalisation.     

Spontaneous coronary artery dissection after a natural course for 10 years--a case report.

We encountered a patient with spontaneous coronary artery dissection complicated by acute inferior myocardial infarction. A 58-year-old male was admitted to our hospital due to acute inferior myocardial infarction in 1979. Coronary angiography performed 4 weeks after the onset showed a double lumen divided by a linear intimal flap in the right coronary artery, suggesting coronary artery dissection, but no apparent occlusion. Subsequently, he had been medicated with nitrates without any recurrent infarction. In February, 1989, 10 years after the first examination, coronary angiography was again performed and showed that the dissection had remained unchanged. Acetylcholine infusion into the right coronary artery induced coronary spasm. The prognosis of this condition seems to be better than has been generally considered, particularly in patients such as ours in whom the involvement of coronary spasm in the development of coronary artery dissection and myocardial infarction is suggested. When coronary spasm in controlled by treatment with nitrates or calcium antagonists, an uneventful course may be expected.     

Spontaneous coronary artery dissection as a rare cause of an acute coronary syndrome

Spontaneous coronary artery dissection is a rare cause of an acute coronary syndrome. This report describes a previously healthy woman without cardiovascular risk factors who presented with an acute anterior non-ST elevation myocardial infarction. Coronary angiography revealed an isolated longitudinal dissection in the middle part of the left anterior descending coronary artery (LAD) with normal flow of the contrast media. The patient was treated conservatively with heparin, aspirin, clopidogrel, and beta-receptor blocker. Stress exercise test was normal at discharge. After an event-free follow-up of three and a half months coronary angiography showed a completely normal LAD. Literature about epidemiology, pathogenesis, diagnosis and treatment of spontaneous coronary artery dissection is reviewed.     

Spontaneous coronary artery dissection on the 10th post-partum day: a case report

Spontaneous coronary artery dissection is a rare cause of myocardial infarction. It most commonly occurs in young women in the peri-partum period. The aetiology remains obscure. The authors describe the case of a 38 year old woman who suffered an inferior wall myocardial infarction on the 10th post-partum day. After failure of thrombolysis, coronary angiography showed dissection of the right coronary artery. An attempted angioplasty was unsuccessful and the patient was treated medically with a favourable clinical outcome. Spontaneous coronary artery dissection should be considered in all young patients without coronary risk factors presenting with acute myocardial ischaemia, especially young women in the peri-partum period. Emergency coronary angiography should be undertaken to establish the diagnosis and orientate appropriate treatment which may be medical, interventional or surgical.     

Significant left main coronary artery disease from iatrogenic dissection during coronary angiography

Though atherosclerotic obstruction is the major cause of the obstructive left main coronary artery (LMCA) disease, it can be associated with iatrogenic dissection during coronary angiography. Here we report a case with severe LMCA stenosis due to catheter induced dissection in a 77-year-old man which was detected 9 months later. By careful review of the angiogram had taken at 9 months ago, the LMCA was injured by the diagnostic left Judkin's catheter during the first coronary angiography. The initial lesion was neglected and the dissection got worse with time. The patient was successfully treated with two drug-eluting stents by crushing technique and discharged without further complication.     

Acute type A aortic dissection in a patient with ventricular septal defect

We report the case of a 38-year-old man with a long-standing history of a small ventricular septal defect presented with chest pain. Electrocardiography revealed sinus rhythm, ST-segment elevation in leads V1–6. The chest X-ray showed mild cardiomegaly. He underwent cardiac catheterisation laboratory to primary coronary angioplasty. Coronary angiography showed normal coronary arteries. Aortic root angiography revealed type A aortic dissection. Transthoracic and transesophageal echocardiography showed aortic dissection in ascending aorta and a perimembranous ventricular septal defect. Thoracoabdominal CT angiography confirmed the aortic dissection before the surgery.The patient underwent cardiac surgery immediately. The ventricular septal defect and aortic dissection were repaired successfully. The postoperative recovery was uneventful and he has thus far remained asymptomatic at 6 months' follow-up.     

Postpartum spontaneous coronary artery dissection: an important clinical link with anticardiolipin antibody

A 34-year-old woman presented to the Emergency Department with substernal chest pain, 7 days after a normal vaginal delivery. Acute myocardial infarction was diagnosed based on ECG changes and elevated serum troponin levels. Coronary angiography revealed a spontaneous coronary dissection of the left anterior descending (LAD) coronary artery. The patient was managed medically and recovered well clinically with healing of the dissection on repeat angiography 10 days later. Of note the patient had a high titre of anticardiolipin antibody (IgM) detected and this is only the second case described in the literature of an association between spontaneous coronary artery dissection and antiphospholipid antibody syndrome.     

Successful endovascular treatment of iatrogenic coronary artery dissection extending into the entire ascending aorta

Iatrogenic acute dissection of the ascending aorta during percutaneous coronary intervention occurs rarely. Localized aortic dissections may be treated by sealing the entry with a coronary stent. However, extensive dissections may require a surgical intervention. A case of iatrogenic coronary dissection with extensive propagation into the ascending aorta during angioplasty of the right coronary artery is presented. The aortic dissection was successfully treated by stenting at the right coronary artery ostium. Follow-up computed tomography and coronary angiography showed complete resolution of aortic dissection.     

Spontaneous healing of spontaneous coronary artery dissection: a case report

Spontaneous coronary artery dissection (SCAD) is an extremely rare cause of myocardial ischemia. It is more prevalent in young women, particularly in the peripartum period. We report a case of SCAD occurring in a 40-year-old non-pregnant woman who presented with acute coronary syndrome. Coronary angiography revealed dissection in the mid and distal portions of left anterior descending artery. She was treated with medical therapy and repeat coronary angiography at 2 months showed no signs of the previous dissection.