Traumatic Coronary Artery Dissection: A Case Report and Literature Review

Background: Coronary artery dissection after blunt chest trauma is a rare, life-threatening condition. Objectives: To present a case of coronary artery dissection after blunt chest trauma and to outline the appropriate management of this condition based on a literature review. Case Report: We report the case of a 50-year-old woman with traumatic coronary artery dissection after a high-speed motor vehicle collision. She presented to the Emergency Department via ambulance within a few hours of the collision, and her clinical condition deteriorated rapidly. A 12-lead electrocardiogram on arrival demonstrated anterolateral ST-segment elevation. The patient was intubated due to hypoxemic respiratory failure and she required inotropes for blood pressure support. Computed tomography imaging revealed pulmonary edema and right third and fourth rib fractures. Emergent angiography demonstrated dissection of her left main coronary artery, requiring placement of a stent. Conclusion: Early recognition of this clinical entity with a screening electrocardiogram, and aggressive management, may result in a favorable outcome. A literature review reveals that coronary artery bypass grafting, angiography with stent placement, and conservative management may all be considered viable treatment options for this condition.     

Coronary artery occlusion following blunt chest trauma: a case report and review of the literature

Blunt chest trauma causing coronary artery occlusion and myocardial infarction is a rare but potentially fatal condition. We present the case of a healthy 29-year-old man who developed a myocardial infarction due to complete occlusion of the proximal right coronary artery following blunt chest trauma. A review of the literature found 63 cases of previously healthy patients under 40 years of age who developed coronary artery occlusion following blunt chest trauma; diagnosis in all cases had been proven by angiography or during autopsy. The presentation, results of electrocardiography and echocardiography and laboratory findings of these patients are described.     

Serial intracoronary ultrasound in children: feasibility, reproducibility, limitations, and safety.

Pediatric patients with heart transplants and Kawasaki disease are at risk to develop coronary artery disease. Selective coronary angiography underestimates vasculopathy in transplant patients and intimal changes in Kawasaki disease. Routine intracoronary ultrasound imaging in adults accurately identifies histopathologic features not visualized by angiography. Little data are available regarding safety and efficacy in children. This study provides sequential data and experience in children between the ages of 2 1/2 and 22 years. Thirty-two patients underwent 62 intracoronary ultrasound examinations at the time of coronary angiography. Careful correlation of the ultrasound crystal locations with the angiographic images of the vessels was made. Images were analyzed for intimal hyperplasia and luminal diameters. Intracoronary ultrasound was more sensitive than angiography in detecting vessel wall disease. Coronary vasospasm occurred in 11 of 62 studies after the intracoronary ultrasound study. All but 1 episode were asymptomatic and resolved after intracoronary nitroglycerine. When a standard protocol is followed and current technology is used, intracoronary ultrasound is feasible, reproducible, efficacious, and safe in the young patient. It allows earlier detection of vasculopathy and intimal disease at angiographically normal sites. As technology improves and greater experience is gained, the long-term safety and prognostic value of these studies in children should be forthcoming.     

Long-term follow-up of coronary artery dissection due to blunt chest trauma with spontaneous healing in a young woman

We report a previously healthy 17-year-old woman who experienced coronary artery dissection with an acute transmural anterior myocardial infarction and myocardial contusion following blunt chest trauma in a motorcycle accident. A chest roentgenogram on admission was normal, and an electrocardiogram showed an acute transmural anterior myocardial infarction with complete right-bundle-branch block. A 2D echocardiogram revealed an akinesis of the anterior wall and a hypokinesis of the posterior wall in the left ventricle. Initial coronary angiography demonstrated severe stenosis with delayed antegrade filling in the proximal left anterior descending artery. Technetium-99m pyrophosphate myocardial scintigraphy demonstrated diffuse tracer uptake in the left ventricular wall. Follow-up coronary angiography performed 1 year after the accident showed a minor stenosis without any filling defects. We describe long-term follow-up of the coronary artery dissection following blunt chest trauma with spontaneous healing.     

Case of the month: Right coronary artery dissection following sports-related blunt trauma

Coronary artery dissection is a rare life-threatening complication resulting from blunt traumatic injury. Most cases of coronary artery injury, including dissection, involve the left anterior descending artery given its anatomical location relative to the impact. Right coronary artery (RCA) dissection secondary to blunt trauma is a particularly unusual occurrence, and has not previously been reported in the emergency medicine literature. We present a case of RCA dissection following low impact sport-related blunt chest trauma and discuss the pathophysiology, risk factors, diagnosis and current treatment options.     

Case of the month: Right coronary artery dissection following sports‐related blunt trauma

Coronary artery dissection is a rare life‐threatening complication resulting from blunt traumatic injury. Most cases of coronary artery injury, including dissection, involve the left anterior descending artery given its anatomical location relative to the impact. Right coronary artery (RCA) dissection secondary to blunt trauma is a particularly unusual occurrence, and has not previously been reported in the emergency medicine literature. We present a case of RCA dissection following low impact sport‐related blunt chest trauma and discuss the pathophysiology, risk factors, diagnosis and current treatment options.     

Blunt traumatic dissection of the proximal left anterior descending artery

Coronary artery dissection secondary to blunt chest trauma is a rare occurrence recently reported in the Emergency Medicine Journal. The case here is reported of a left anterior descending artery dissection after blunt chest trauma to illustrate a different, more precipitous presentation of this condition after severe trauma. This case report highlights how clinical history can alert to the presence of this complication and how electrocardiography is fundamental to risk stratification after trauma, and discusses management alternatives for this condition in the setting of multi-trauma.     

Left anterior descending artery occlusion secondary to blunt chest trauma diagnosed by comprehensive echocardiography and coronary angiography

Blunt chest trauma can cause serious complications, but coronary artery occlusion is rare. In a 19-year-old man, 40 days after a motorcycle accident, comprehensive echocardiography detected left anterior descending artery occlusion and left ventricular dysfunction, which was confirmed by coronary angiography and ventriculography. Echocardiography was also able to confirm restored left anterior descending artery flow and improved left ventricular function after coronary artery bypass grafting.     

Cryoablation at Growing Myocardium: No Evidence of Coronary Artery Obstruction or Intimal Plaque Formation Early and Late after Energy Application

Background: Animal studies and clinical observations have demonstrated that radiofrequency current application at growing myocardium may result in coronary artery obstruction. Recently, cryoenergy has emerged as an effective alternative to radiofrequency ablation of arrhythmogenic substrates in pediatric patients. Up to now, there has been a lack of experimental data concerning the effects of cryoenergy application at growing myocardium.
Methods: During general anesthesia, selective coronary angiography of the right and left coronary artery was performed in 10 piglets (age: 6 weeks, body weight: 14–18 kg). Subsequently, cryoenergy was delivered at −75°C for 4 minutes using a 7-F catheter with a 6-mm-tip electrode at the atrial aspect of the tricuspid valve annulus in a posterior and lateral position. Additional cryoenergy lesions were induced via a retrograde approach at the lateral and posterior atrial and ventricular aspect of the mitral valve annulus, respectively. Five animals were restudied after 48 hours by coronary angiography and intracoronary ultrasound and in the remaining five piglets after 3 and 6 months, respectively.
Results: Selective coronary angiography and intracoronary ultrasound studies did not demonstrate any evidence for coronary artery obstruction after 48 hours, 3 months, or 6 months after cryoenergy application. In addition, histological examinations of the cryolesions after 48 hours and after 6 months did not demonstrate any intimal proliferations of the coronary arteries, respectively.
Conclusions: By means of the present study, we did not observe any affection of the coronary arteries after cryoenergy application at growing myocardium in young piglets.     

Renal artery stenting for intimal flap injury in a 2-year-old child after blunt abdominal trauma

Injury to the renal vasculature is an uncommon occurrence in the setting of blunt abdominal trauma. The authors report the case of a 2-year-old girl who developed occlusion from an intimal flap in a renal artery (grade IV renal injury) after blunt abdominal trauma that was treated with a stent placement. The stent procedure was technically successful in establishing renal artery flow. However, several months after the procedure, the patient developed stenosis within the stent and ultimately required a nephrectomy. To the authors' knowledge, this is the first report of percutaneous management of an acute intimal flap in a renal artery in a 2-year-old.     

血管内超声对粥样硬化冠状动脉成像的研究

研究目的在于评价血管内超声（ＩＶＵＳ）观察粥样硬化冠状动脉（ＣＡ）的安全性和可行性。利用３．５Ｆ，３０ＭＨｚ超声导管对１１例冠心病患者的２０支冠状动脉节段进行了检查，所有病人均顺利接ＩＶＵＳ检查，５例血管造影提示冠脉左主干正常的血管段，ＩＶＵＳ显示有内膜轻度增厚或局灶性斑块，１５支血管造影提示ＣＡ管腔狭窄的血管段，ＩＶＵＳ发现有中至重度的内膜增厚，操作中未发现严重并发症。结论：血管内超声检查是安全可行的，它可提供异常ＣＡ管壁形态学的详细信息。     

Cardiac contusion following blunt chest trauma.

Cardiac contusion following blunt chest trauma is not rare, and the works in the literature report incidence rates between 5 and 50%. Traffic accidents are the most frequent cause of cardiac contusion followed by violent fall impacts, aggressions and the practice of risky sports. The spectrum of post-traumatic cardiac lesions varies greatly, ranging from no symptoms to decrease in cardiac function. Cardiogenic shock is a rarely encountered manifestation of blunt cardiac contusion. We review our experience of cardiac contusion after blunt chest trauma, and we describe two very severe cases that manifested as cardiogenic shock. We emphasize an early diagnosis by continuous electrocardiographic monitoring, serial electrocardiograms, echocardiography, serum determination of biochemical cardiac markers, radionuclide imaging and coronary angiography. The treatment includes continuous monitoring of cardiac rhythm, use of inotropic drugs, insertion of a catheter in the pulmonary artery for continuous assessment of cardiac output and, in extreme cases, the insertion of a contrapulsation balloon to maintain haemodynamics until improvement of cardiac function.     

A PATHY I S N OT W ELCOME H ERE

Abstract

A 41-year-old motocross rider sustained blunt trauma to the chest following a collision with another rider. He was initially hypoxic and was given oxygen with a non-rebreather mask. He complained of chest pain. A prehospital extended focused assessment with sonography in trauma (eFAST) scan was negative for pneumothorax, but demonstrated a hypokinetic left ventricle. An electrocardiogram (ECG) in the emergency department confirmed anterior myocardial infarction, found to be due to a traumatic left anterior descending coronary artery dissection. This case highlights a rare but life-threatening cause of hypoxia in blunt chest trauma.     

Rupture of the coronary artery after blunt nonpenetrating chest wall trauma detected by color Doppler echocardiography: a case report.

We report a rare case of a ruptured papillary muscle of the anterior leaflet of the tricuspid valve and the rupture of the septal branch of the left anterior descending coronary artery with drainage into the right ventricle after blunt nonpenetrating chest wall trauma. Both abnormalities were detected by transthoracic 2-dimensional and color Doppler echocardiography, and the septal branch rupture was confirmed by coronary angiography. The leading echocardiographic sign of the rupture of the coronary artery was intramyocardial mosaic-colored flow, representing the turbulent high-velocity flow in the ruptured coronary artery. Hypokinesis of the anteroseptal myocardial segments and the presence of Q waves in leads V1 through 4 on the electro-cardiogram were suggestive of anteroseptal myocardial infarction. We conclude that the history of chest trauma, the electrocardiographic changes, and wall motion abnormalities should be stimuli for a careful color Doppler flow "mapping" of the myocardium for possible identification of a coronary artery rupture.     

MRI demonstration of acute myocardial infarction due to posttraumatic coronary artery dissection

A case of left ventricular lateral wall myocardial infarction in the distribution of circumflex coronary artery (LCX) was demonstrated by magnetic resonance imaging in a 55-year-old woman. Dissection of the proximal LCX due to blunt chest trauma was followed by percutaneous coronary artery stenting. MR (magnetic resonance) imaging of myocardial infarction is reviewed.     

Traumatic dissection of a coronary artery: detection by multislice computed tomography and use of tirofiban as a reversible platelet inhibitor

We report on a trauma victim without history of or risk factors for cardiac disease, who suffered coronary artery dissection caused by blunt chest injury (BCI). Myocardial ischaemia was detected by multislice computed tomography (MSCT) promptly after trauma centre admission and managed by immediate revascularisation.Thoracic trauma may cause myocardial ischaemia in the absence of a specific risk profile. MSCT, as part of initial work-up in severely injured patients, may support differential diagnosis after BCI. Tirofiban and unfractionated heparin as short-acting anticoagulants warrant stent patency and concurrently offer the possibility of quick recovery of haemostasis in case of haemorrhage.     

Delayed diagnosis of post-traumatic acute myocardial infarction complicated by congestive heart failure

A 53-year-old man experienced persistent chest pain followed by slight shortness of breath after being hit in the chest by a stranger. Chest X-ray study showed no rib fractures but electrocardiography indicated acute anterior wall myocardial infarction. Echocardiography revealed akinesia in both the interventricular septum and anterior left ventricular wall. Emergency cardiac catheterization demonstrated total occlusion of the proximal left anterior descending coronary artery, 9 h after the event. He was successfully treated with coronary angioplasty and stenting procedures. However, poor left ventricular function was observed 3 months after the event despite medications. We conclude that evaluation for possible myocardial injury should be considered soon after blunt chest trauma for early treatment to improve prognosis.     

Significance of intravascular ultrasound and exercise stress echocardiography in diagnosis of exercise-induced vasospastic angina at the site of moderate stenosis

Recently, exercise-induced spastic coronary artery occlusion at the site of moderate stenosis, which Prinzmetal’s angina or cardiac syndrome X does not cover, was reported. Multi-modality imaging is important for the diagnosis of coronary artery disease with a complex ischemic mechanism. However, the previous report did not include findings from intracoronary imaging at the site of moderate coronary stenosis. We report a case of exercise-induced vasospastic angina at the site of moderate stenosis, where multi-modality imaging, including exercise stress echocardiography and intravascular ultrasound, was utilized to make a definitive diagnosis and investigate underlying causes.     

Acute aortic dissection mimicking an acute coronary syndrome through occlusion of the right coronary artery

Occlusion of the right coronary artery (RCA) is an uncommon complication of type A aortic dissection. Aortic dissection and acute coronary syndrome (ACS) share a similar pathogenesis in atherosclerosis and hypertension. Consequently a patient with ischaemic risk factors presenting with chest pain and dynamic ECG change may well be incorrectly treated for ACS if careful attention is not paid to the presenting symptoms and signs. This case report describes a 59-year-old man who presented with chest pain, confusion and an ischaemic ECG and was initially treated for ACS. He subsequently deteriorated clinically and imaging confirmed type A aortic dissection complicated by RCA occlusion. Following emergent surgery with aortic root replacement and coronary artery bypass grafting he later made a good recovery.     

Traumatic type B aortic dissection causing near total occlusion of aortic lumen and diagnosed by transthoracic echocardiography: A case report.

A true dissection of the descending thoracic aorta resulting from blunt chest trauma is a relatively rare injury compared with aortic transsection and occurs mostly in the region of the aortic isthmus. It is a life-threatening condition that requires rapid and accurate diagnosis. In this case, we report a patient with Stanford type B aortic dissection caused by decelerating trauma of the chest in a motor vehicle accident causing near total occlusion of the aortic lumen. The diagnosis was made by transthoracic echocardiography and confirmed by aortography.