Left main coronary artery dissection during
percutaneous coronary intervention treated by
R.B. Hokken, D. Foley, R. van Domburg, P.W. Serruys
Aim. Outcome after stenting for iatrogenic left main coronary artery (LMCA) dissection during percutaneous coronary intervention (PCI). Methods. From our database all patients with a PCI complicated by an LMCA dissection, between 1996 and 2001, were selected and medical records were reviewed. Results. Eighteen patients out of 7199 (0.25%) were found with an LMCA dissection during a PCI for unstable (n=14) and stable angina (n=4). Antegrade dissections were caused by guiding catheters (n=6). Retograde dissections were caused by stent implantation (n=7) and balloon angioplasty (n=5). All patients were treated by stent implantation in the LMCA. Three patients died (17%) within ten days ofthe procedure. Emergency surgery was performed in four patients (22%) because ofpersistent ischaemia due to low coronary flow. One patient was operated one day later because ofunstable angina and a failed attempt to recanalise the left descending coronary artery. The other ten patients (56%) with a stent in the LMCA were free of cardiac complaints after a follow-up period of 3.0 years (range 1.9-5.0). Cardiac catheterisation in six-patients between three and eight months did not show stenosis ofthe LMCA stent. Conclusion. LMCA dissection during a PCI can be treated by stent implantation, especially when the dissection is limited to the LMCA. When flow cannot be restored adequately, resulting in ischaemia and haemodynamic instability, LMCA stenting may serve as a bridge to emergency CABG. (Neth Heart J 2002;10:395-8.) R.B. Hokken. D. Foley. R. van Domburg. P.W. Senuys. Department of Cardiology, Erasmus University Medical Centre, Dr. Molewaterplein 40, 3015 GD Rotterdam. Address for correspondence: R.B. Hokken. E-mail: [email protected]
Netherlands Heart Journal, Volume 10, Number 10, October 2002
Key words: left main coronary artery, dissection, percutaneous coronary intervention, stent A percutaneous coronary intervention (PCI) is a relatively safe procedure. Complications, however, may occur, ranging from small haematomas at the puncture site to cerebrovascular accidents or intracoronary obstruction resulting in ischaemia or myocardial infarction followed by malignant arrhythmias or haemodynamic instability.'-3 Intracoronary obstruction may be due to a dissection. When these dissections are small and without haemodynamic interference there are no clinical consequences.4 5 Large dissections may lead to abrupt closure by compression ofthe true lumen, thrombus formation or vessel spasm. In the early years of balloon angioplasty, insertion of an intra-aortic balloon pump (IABP) followed by emergency surgery was the only solution to this complication. Repeating balloon dilatation, use of a perfusion balloon, stenting ('bailout stenting') and intracoronary administration of thrombolytic agents have been used as treatment or as a bridge to (emergency) surgery.26 When the dissection extends within the left main coronary artery (LMCA), with interrupted flow or occlusion, a life-threatening situation exists since a greater part of the myocardium is at risk. The treatment of choice used to be emergency surgical revascularisation.78 Since the implantation of stents has increased explosively in recent years, with improved results due to improved stent design, implantation techniques and operator experience, stent implantation may be an alternative to emergency surgery or may serve as a bridge to emergency surgery when an LMCA dissection occurs. Therefore, we reviewed our experience on treatment ofLMCA dissection during a PCI in our institution.
Methods From our catheterisation laboratory database (from 1 January 1996 to 1 January 2001), 18 out of 7199 patients (0.25%) were selected with a PCI complicated by an LMCA dissection. Medical records were reviewed for baseline characteristics, PCI procedures, 395
Left main coronary artery dissection during percutaneous coronary intervention treated by stenting
causality of LMCA dissection, treatment ofthis complication and short-term outcome. Follow-up ofthese patients was completed with regard to mortality, repeated PCI, coronary artery bypass grafting (CABG), control catheterisation ifavailable and clinical status at last follow-up. PCIs were performed via the femoral route using a 6 French catheter. All patients received aspirin 250 mg iv and 5000 to 10,000 units heparin iv (ACT >300 seconds). Intracoronary nitrate 0.1-0.3 mg was used liberally to control vasomotor tone and facilitate online quantitative coronary angiography (QCA). During this period stents were implanted after predilatation or directly, according to the choice of the treating physician. A wide range of stents were available in this five-year period. Of the patients undergoing an LMCA dissection, treatment was carried out according to the treating physician's preference, in consultation with the consulting surgeon when haemodynamic instability was present. Results In 18 out of 7199 patients (0.25%) a PCI was complicated by an LMCA dissection. Baseline characteristics are presented in table 1. None of the patients had a history of CABG so all LMCAs were 'unprotected' when the dissection occurred. Indication for intervention was stable angina in four patients and unstable angina in 14 patients. The initial target vessel was the left anterior descending artery (LAD) in 15 patients, the circumflex artery (CX) in two patients and the intermediate artery in one patient. The cause of LMCA dissection was a lesion by the guiding catheter in six patients (unstable angina in four patients) resulting in small localised dissections in five patients and one antegrade dissection to LAD and CX; one patient was included in which the LMCA dissection was caused by an intravascular ultrasound (IVUS) catheter, used to evaluate a treated LAD dissection (figure 1). Retrograde dissections were caused by balloon angioplasty in five patients, including three patients in which recanalisation of a coronary artery was attempted (LAD in 2 patients and CX in 1 patient). In seven patients
Table 1. Baseline characteristics of 18 patients with LMCA dissection during PCI. Variable
Age Male gender Risk factors: - Smoking - Diabetes - Hypercholesterolaemia - Hypertension - Affected family - No risk factor Previous MI Previous PTCA Left ventricular function: - Good - Moderate
63.1 years (range 39.1-83.7) 10 (56%) 4 (22%) 1( 6%) 11 (61%) 5 (28%)
8 (44%) 4 (22%) 7 (39%) 4 (22%) 15 (83%) 3 (17%)
the implantation of a stent resulted in a retrograde dissection to the LMCA (figure 2). All LMCA dissections were treated with stent implantation (figures 1 and 2). In 14 patients stent implantation was limited to the LMCA, in three patients the stent was placed across the ostium of the CX and in one patient a bifurcation stent was used. The stents used for the LMCA were NIR stents (6 patients), BX Velocity stents (4 patients), a Multilink stent (1 patient) and a Jomed bifurcation stent (1 patient). In six patients the LMCA stent was not recorded. An IABP was inserted in five patients. Two patients died within 24 hours. One 76-yearold male patient with unstable angina and good left ventricular (LV) function experienced a retrograde dissection after balloon angioplasty of the CX. Repeated thrombus formation in the LMCA and permanent closure of the CX resulted in ongoing ischaemia and cardiogenic shock, despite stenting of LMCA, CX and LAD, insertion of an IABP and
Figure 1. Small, localised LMCA disection (arrow) caused by an IVUS cateter in a 67-year-old patient after stent implantation in the LAD, before (a) and after (b) stent implantation.
Netherlands Heart Journal, Volume 10, Number 10, October 2002
Left main coronary artery dissection dunng percutaneous coronary intervention treated by stenting
Figure 2. Retrograde dissection of the LMCA (arrow) originating from the LAD after stent implantation in the latter in a 77-year-old patient. (a) After stent implantation the doubk lumen appearance was vanished. (b) The proximal LAD and CX were treated as well.
administration oftrombolytic, inotropic, vasodilating agents and abciximab. This patient was not accepted for emergency surgery. A second patient (female, 67 years old) with stable angina and a good LV function was initially haemodynamically stable with pericardial effusion caused by a wire exit in the distal LAD together with the administration of abciximab. A cardiac tamponade evolved with haemodynamic instability and ventricular fibrillation requiring reanimation. Percutaneous drainage was not adequate and after surgical evacuation asystole evolved, resistant to resuscitation. A 59-year-old male with moderate LV fimction was septic after a diagnostic puncture of an abdominal lymphoma. He developed myocardial ischaemia with cardiogenic shock. Mechanical ventilation was started and the LAD was stented. The guiding catheter caused a (localised) LMCA dissection which was treated successfully, abciximab was given and an IABP was inserted. Abdominal surgery for intestinal perforation followed one day later; aspirin and clopidogrel were instituted. Nine days later this patient became respiratory insufficient due to a pneumonia and needed mechanical ventilation. A few hours after intubation he died due to an acute circumferential myocardial infarction, confirmed by pathological examination. Four patients were referred for emergency surgery because of persistent ischaemia due to low coronary flow or occlusion in the LAD (2 patients) or CX (2 patients), including one patient with haemodynamic instability. In three of these patients an IABP was inserted. One other patient with unstable angina and failed recanalisation of the LAD was operated on one day later. The LAD, diagonal branch and CX were grafted in all five patients and the intermediate artery in one patient. In ten patients (including 6 patients with retrograde LMCA dissections) LMCA stenting resulted in haemodynamically stable patients with open LAD and CX. These patients were treated with aspirin and ticlopidine (n=4) or clopidogrel (n=6). Abciximab was
Netherlands Heart Joumal, Volume 10, Number 10, October 2002
given to four patients. Cardiac enzymes were elevated in seven patients from a little above the upper creatinine kinase level (4 patients) to four times the upper creatinine kinase level (3 patients). Occlusion of a septal branch, a diagonal branch, an intermediate branch and a posterolateral branch of the right coronary artery (RCA) could be related to these elevations. Discharge of these patients was one day later in seven of them and five, six and seven days later in the others. Control angiography was performed in six patients after three to eight months without restenosis of the LMCA. No patients died during follow-up. Repeated PCI for the LMCA was not necessary. Three patients required a PCI for other coronary sites (RCA in 3 patients, diagonal branch in 1 patient, LAD in 1 patient); one patient was referred for CABG five months later because of restenosis of a right coronary artery. With a mean follow-up of 3.0 years (range 1.95.0 years), these patients are without cardiac complaints.
Discussion Balloon angioplasty may be complicated by abrupt vessel closure due to acute thrombosis, distal embolisation or thrombus and, most often, dissection of the coronary artery. However, dissection of the coronary artery is intentionally induced to dilate the stenotic segment and when this is not seen on angiography the dilation is regarded as a success. Even small, visible dissections without flow disturbance do not need repeat intervention.4'5 For haemodynamically important dissections IARP insertion followed by emergency surgery was the first option in the early years of balloon angioplasty. Nowadays, dissections can be treated by percutaneous techniques, especially stent implantation.69 The incidence of (antegrade) dissections of the LMCA is known from diagnostic catheterisations.'10'l For (antegrade and retrograde) dissections ofthe LMCA during PCIs this is not known since there are only anecdotal reports describing this issue.'2"15 In the reviewed period, the 18 patients in our institution represent an incidence of 0.25%. During 397
Left main coronary artery dissection durng percutaneous coronary intervention treated by stenting
a PCI the guiding catheters are used to support the guide wire and balloon or stent placement, with high pressures on the coronary wall. In our series this resulted in a dissection linited to the LMCA in five patients and extended to the LAD and CX in one other patient. A retrograde large dissection ofthe LMCA is more difficult to treat because other coronary arteries than the LMCA may be dissected needing surgical intervention; in our series this concerned four out of 13 patients. Emergency surgical revascularisation is still the preferred treatment option in most intervention centres. However, the main disadvantage ofthis option is the delay in revascularisation resulting in high mortality and morbidity due to extended ischaemia or infarction with malignant arrhythmias or severe haemodynamic instability.2 Stent implantation in the LMCA may restore coronary flow much earlier and may serve as a bridge to (emergency) surgery or may even be therapeutic. The feasibility of LMCA stenting has been shown in patients with LMCA stenosis for which elective stent implantation was scheduled.'6-'8 The risk in these patients may be reduced when the LAD or CX arteries are 'protected' by a functional graft or extensive collateral circulation.'9 Literature concerning stent implantation in the LMCA in an emergency setting is anecdotal.'2-'5 In this series ten patients with an LMCA dissection during a PCI without 'protected' coronary arteries were treated with LMCA stenting, with good midterm results. Although we acknowledge the small number of patients and the retrospective character ofthis study, we conclude that an LMCA dissection during a PCI can be treated by stent implantation, especially when the dissection is limnited to the main stem as it usually is by catheterinduced dissection. Extended retrograde dissection to the LMCA, and eventually the origin of both LAD and CX, can also be managed by stent implantation in order to restore flow to the greater part of the myocardium as soon as possible. When flow cannot be maintained adequately, resulting in ischaemia and haemodynamic instability, LMCA stenting may serve as a bridge to emergency surgery. U References 1 2
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Nethcrlands Heart Journal, Volume 10, Number 10, October 2002