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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 26, No 6, November/December 2015
AFRICA
e5
Case Report
Iatrogenic left main-stem dissection extending to
the circumflex artery and retrogradely involving the
left and non-coronary sinuses of Valsalva: iatrogenic
aortocoronary dissection
Radosław Zwoli
ń
ski, Anna Marcinkiewicz, Konrad Szymczyk, Robert Pietruszy
ń
ski, Ryszard Jaszewski
Abstract
We present the case of a 57-year-old female who experienced
iatrogenic left main-stem (LMS) dissection during elective
coronary angiography. The dissection immediately affected
the circumflex artery (Cx), causing its total distal occlusion,
and the left anterior descending artery (LAD), in which a
metal stent, implanted six months earlier, provided blood
flow. The dissection spread retrogradely to the left and
non-coronary sinuses of Valsalva (SV). Ventricular fibrilla-
tion (VF) occurred but the patient was successfully defibril-
lated. The subsequent introduction of a catheter resulted in
recurrent VF, again successfully defibrillated. Total arterial
myocardial revascularisation with double skeletonised inter-
nal thoracic arteries was performed without complications
and SV repair was avoided. At the one-year follow up, a
control multi-slice CT (MSCT) angiography was conducted,
revealing complete healing of the SV and LMS dissections. It
also showed native blood flow, the left internal thoracic artery
(LITA) graft to the Cx occlusion, and a patent right internal
thoracic artery (RITA) graft implanted to the LAD.
Keywords:
left main-stem dissection, limited aortic dissection,
coronary angiography
Submitted 25/11/14, accepted 26/7/15
Cardiovasc J Afr
2015;
26
: e5–e7
www.cvja.co.zaDOI: 10.5830/CVJA-2015-060
According to the simplified classification, iatrogenic left main-stem
(LMS) dissection involving the aortic root is the rarest and most
life-threatening type of dissection. The incidence of iatrogenic
aortic root dissection is estimated to be 0.02%. In the majority of
cases it remains confined to the coronary sinus of Valsalva (SV).
1
Although therapeutic management of LMS dissection
involving SV is demanding, there are few published works in this
field.
2-4
There are neither guidelines nor consensus among experts
on how to manage LMS and retrograde SV dissection during
percutaneous procedures. The published literature on iatrogenic
dissection describes the following therapeutic solutions: surgical
revascularisationwith SV repair, including usage of an autologous
patch; percutaneous angioplasty with stent(s) implantation to
cover the ostial dissection; and conservative treatment, which can
provide spontaneous healing of the dissection.
1-4
Case report
A 57-year-old patient with well-controlled arterial hypertension,
hyperlipidaemia and anterolateral ST-elevation myocardial
infarction (STEMI) was treated with a primary bare-metal
stent (BMS) implantation to the left anterior descending artery
(LAD). Six months later, she underwent an elective coronary
angiography due to exacerbated angina pectoris. On admission,
she was classified as class III according to the Canadian
Cardiovascular Society classification (CCS).
During coronary angiography, the angiogram showed both
the positive long-term effect of the BMS implantation and the
absence of any significant progression of previously described
atherosclerotic lesions. After completing the left coronary artery
examination, the patient started complaining of chest pain. At
the same time the electrocardiogram (ECG) showed ST-segment
elevation. As the patient became symptomatic, catheterisation
of the left coronary artery was repeated. A standard diagnostic
coronary catheter, Impuls 6-Fr JL3.5 Boston (guidewire 6-Fr
JL3.5 Medtronic Launcher) was used. This time the examination
revealed LMS dissection, antegrade dissection of the circumflex
artery (Cx) causing distal occlusion of blood flow, and contrasting
of the left aortic bulb (Fig. 1). Instant ventricular fibrillation
(VF) occurred but the patient was successfully defibrillated. The
cardiologist immediately attempted to cover the dissection with
a stent, but VF recurred, and was again successfully treated with
defibrillation.
Department of Cardiac Surgery, Clinical Teaching Centre,
Medical University of Lodz, Lodz, Poland
Radosław Zwoli
ń
ski, MD, PhD
Anna Marcinkiewicz, MD,
annamar87@o2.plRyszard Jaszewski, MD, PhD
Department of Radiology: Imaging Diagnostics, Norbert
Barlicki Memorial Teaching Hospital No 1, Medical
University of Lodz, Lodz, Poland
Konrad Szymczyk, MD PhD
Department of Vascular Diagnostics and Procedures, Military
Teaching Hospital, Veterans Central Hospital, Lodz, Poland
Robert Pietruszy
ń
ski, MD, PhD