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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 26, No 6, November/December 2015
AFRICA
e7
Although stenting gives the opportunity of a fast and
direct approach, more than one stent is usually required to
obtain proper blood flow in the LAD and Cx. Furthermore,
percutaneous angioplasty may be associated with extension of
the dissection area. While forming a haematoma, the coronary
artery lumen may become occluded. In a long-term follow up by
Unal and co-workers, after salvage PCI of the dissected LMS,
rates of in-stent restenosis and repeated revascularisation were
high.
6
In addition, LMS dissection can easily affect the main
branches, causing ischaemia in a large mass of myocardium, and
clinical recurrence of angina pectoris.
7
In our case, it seems that the previously implanted BMS
provided blood flow through the LAD but the dissection resulted
in haematoma formation. Although an attempt at covering the
dissection with a stent was undertaken, recurrent VF occurred
with each introduction of the catheter. There was no opportunity
to protect the dissection percutaneously, therefore, a clinical
approach focused on the patient’s stabilisation and transfer to
the cardiac surgery department.
The results of laboratory tests and changes in the ECG
suggested progression of ischaemia. In addition to recurrent
VF, it showed that there was only temporary haemodynamic
stability. In such a scenario, surgical treatment, especially in the
case of limited aortic root dissection and persistent myocardial
ischaemia, was the only reasonable and possible solution. ECG
evolution indicated that the haematoma along the LAD could
have been causing occlusion of the medial and distal segments,
and anterior myocardial ischaemia.
Iatrogenic aortocoronary dissection (IACD) may be treated
conservatively, especially in cases of high-risk patients, provided
that entry of the dissected coronary artery is covered with a
stent and the patient can be carefully monitored.
8
On the other
hand, IACD is unpredictable by nature. A stent implantation
may not prevent type A ascending aortic dissection early after
the primary procedure, therefore, sudden clinical deterioration
may be observed.
9
Spontaneous resolution of the SV dissection,
even within 24 hours post procedure, has also been reported.
8
Some authors suggest the surgical approach when the dissection
extends into the ascending aorta for more than 4 cm.
1
A decision on total, no-touch arterial revascularisation was
made during the surgery. It allowed the blood supply to the
ischaemic myocardial areas to be restored without manipulation
of the ascending aorta. An unchanged sino-tubular junction and
ascending aorta allowed SV repair to be avoided.
The one-year follow up and results of the control MSCT
angiography confirmed the appropriateness of the intra-operative
decision. Healing of the dissection probably caused competitive
native and bypass flow, which contributed to occlusion of the
LITA graft.
The percentage of self-healing dissections is unknown, as is the
mechanism of this process. Almafragi
et al
.
10
suggested that the
healing of a coronary artery dissection is stimulated by retrograde
flow and intravascular pressure augmentation caused by a bypass
implantation. This corresponds with the high rate of in-stent
restenosis. Our decision was confirmed by a favourable outcome
in the patient, and the positive impact of the competitive flow.
Conclusions
IACDposes therapeutic difficulties and individual risk evaluation
may confirm the treatment strategy. Surgical intervention limited
to myocardial revascularisation, performed as a no-touch
technique, and conservative management of the limited aortic
dissection may give satisfactory long-term results. Careful patient
follow up is also required.
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