Journal of Invasive Cardiology

Discussion. Aortocoronary dissection is an extremely infrequent complication of coronary angiography or intervention. There are 28 previously reported cases in the literature (Table 1). Of these cases, 89% (n = 25) involved the RCA, 39% (n =11) were secondary to balloon inflation, 14% (n = 4) were due to wire manipulation, 29% (n = 8) were due to guide catheter manipulation, and 2 cases occurred during diagnostic coronary angiography. The mechanism is different than spontaneous aortic dissection and likely involves disruption of the coronary intima followed by subintimal injection of contrast and retrograde dispersion of contrast or blood. The increased incidence of aortocoronary dissections involving the RCA may be due to inherent differences in the histologic structure of the ostia of the RCA and left main coronary artery (LMCA).8
The optimal treatment for this complication is not established. In the previously reported cases, 64% (n = 18) consisted of localized aortic dissections involving the aortic root or ascending aorta and 36% (n = 10) involved more extensive dissections extending to or beyond the aortic arch, or associated with epicardial contrast. Of the cases involving localized aortic dissections, 50% (n = 9) were treated with intracoronary stenting, 44% (n = 8) were treated conservatively and 1 was treated with coronary artery bypass surgery for a LMCA dissection. Ninety-four percent (n = 17) of the patients with localized dissections survived to discharge. One patient died from refractory ventricular fibrillation after suffering an inferior MI. In the 8 patients who received follow-up imaging, the size of the dissection had decreased in all cases.
Of the patients with extensive dissection, 80% (n = 8) were treated surgically while 1 was treated with intracoronary stenting and 1 was treated conservatively. Seventy-five percent of the surgically treated patients survived to discharge. The stented patient was noted to have a chronic dissection by CT scan at 6 months and to be asymptomatic at 36 months. The conservatively managed patient expired. It is interesting to note that 2 of the 8 patients with extensive dissections were determined to have cystic medial necrosis by histologic exam.
After intracoronary stenting, our patient was determined by TEE to have a localized aortic dissection with no discernable color flow into the false lumen. Thus, a conservative approach of serial non-invasive evaluations of the extent of dissection was pursued. In the current era of coronary intervention, most operators choose to stabilize the lumen of a dissected coronary artery with stenting. Likewise, in the setting of aortocoronary dissection, covering the intracoronary dissection with a stent may seal the entry port of the dissection. This may now be even more effective with the availability of covered stents.
IVUS is a powerful tool that can identify coronary dissections not visible by angiography. Although it has not previously been described in this setting, IVUS imaging may help evaluate for complete coverage of the intracoronary dissection, which presumably will prevent further propagation.