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Delayed coronary artery dissection after angiography
Delayed coronary artery dissection after angiography A case description with successful operative treatment A patient is described in whom right coronary artery dissection occurred 48 hours after coronary angiography. Successful operative treatment consisted of immediate saphenous vein bypass grafting and ligation of the proximal coronary artery. Several aspects of the case are characteristic of this pathological entity as reported in the literature and suggest principles of surgical management.
Lynn H. Harrison, Jr., M.D., David L. Gregg, M.D., Samuel B. Itscoitz, M.D., David R. Redwood, M.D., and Lawrence L. Michaelis, M.D., Bethesda, Md.
.L/elayed coronary artery dissection is a well-known complication both of catheterization and of coronary perfusion. We recently performed an aorto-coronary artery bypass operation to correct this condition in a 44-year-old woman. To our knowledge, operative repair of this lesion has not previously been reported in the literature. Case report A 44-year-old woman was admitted to the National Heart and Lung Institute in January, 1974, for evaluation of atypical angina. She had experienced two episodes of exercise-related chest pain 18 months prior to admission and had been hospitalized 1 year earlier with electrocardiographic and enzyme changes suggesting an anterior myocardial infarction. After that hospitalization, she continued to have chest pain three to four times per week. The patient's father had died of a ruptured femoral artery aneurysm, her mother was hypertensive, and two of her five sisters had
From the Clinic of Surgery and the Cardiology Branch, National Heart and Lung Institute, Bethesda, Md. 20014. Received for publication Nov. 20, 1974. Address for reprints: Lawrence L. Michaelis, M.D., Clinic of Surgery, National Heart and Lung Institute, Bethesda, Md. 20014.
880
sustained myocardial infarctions in middle age, one sister dying at the age of 45 years of an acute infarction. The patient was postmenopausal and had a 20 pack-year history of smoking. Physical examination on admission was unremarkable. The electrocardiogram demonstrated left axis deviation with Q waves in Leads V, to Vj. Fasting serum cholesterol was 170 mg. Exercise testing did not provoke chest pain at a power output of 60 to 80 watts for 5 minutes. Left heart catheterization was performed, including coronary angiography. The left ventricular end-diastolic pressure was 7 mm. Hg, and the left ventricular cineangiogram demonstrated normal contractions. Coronary angiography was performed by percutaneous insertion of the catheter* into the femoral artery.' Coronary angiograms were originally interpreted as normal with a right dominant system (Fig. 1), although retrospective review revealed a small, nonstenotic intimal irregularity in the proximal right coronary artery (see arrow). Forty-eight hours after catheterization, and shortly after a roentgen examination with barium swallow, the patient experienced the sudden onset of crushing substernal chest pain associated with nausea, vomiting, and diaphoresis. The pain was not relieved by 0.4 mg. of nitroglycerine sublingually and 10 mg. of morphine sulfate. Cardiac examination revealed no new findings, but an electrocardiogram demonstrated marked ST-T-wave *Cordis Corp., Miami, Fla.
Volume 69
Number (>
Coronary artery dissection after angiography
881
June, 1975
Fig. 2. Right coronary arteriogram, obtained 45 minutes after the onset of pain, demonstrates a dissection beginning in the proximal portion of the vessel.
Fig. 1. Initial right coronary arteriogram (left anterior oblique projection). Retrospective review demonstrates an area of irregularity (arrow) in the proximal artery which likely represents the site at which dissection began.
changes consistent with diaphragmatic and subendocardial ischemia. Emergency repeat coronary angiography demonstrated a normal left coronary system. However, study of the dominant right system revealed marked changes from its previous appearance (Fig. 2) consistent with medial dissection throughout the entire vertical portion of the artery extending to the acute margin of the right ventricle. N o re-entry point was identified. Serial films showed residual contrast medium in the right coronary artery 30 minutes after injection (Fig. 3 ) . While in the catheterization laboratory, the patient developed ventricular fibrillation, but normal sinus rhythm was restored by countershock. She was taken directly to the operating room where a median sternotomy was performed and cardiopulmonary bypass instituted. Inspection of the heart revealed mottling and dyskinesia of the anterior surface of the right ventricle. The proximal right coronary artery was edematous and discolored, whereas the distal artery was collapsed and pallid. A saphenous vein bypass graft was inserted between the aorta and m i d right coronary artery, and the proximal vessel was Iigated at a point distal to the beginning of adventitial discoloration (Fig. 4 ) . The patient was weaned from cardiopulmonary bypass with ease.
Fig. 3. Thirty minutes after selective injection of the artery, residual contrast material remains in the false lumen of the dissection. We noted that the area of the right ventricle which had been ischemic prior to grafting was now pink and contracted well. The patient's postoperative course was benign, and she was discharged on the twelfth postoperative day. She has since been followed as an outpatient and remains well. Six months after the operation, angiography demonstrated a widely patent graft with excellent filling of the recipient right coronary artery (Fig. 5 ) . Left ventriculography revealed a hypokinetic inferior wall with a small zone of akinesia in its midportion.
Comment To our knowledge, operative repair of a delayed coronary artery dissection has not previously been reported, although this entity has been well documented as a compli-
The Journal of
8 82
Harrison et al.
Thoracic and Cardiovascular Surgery
=
\
Fig. 4. The operation consisted of saphenous vein bypass grafting from the aorta to the coronary artery distal to the dissection. The artery was ligated past the origin of dissection to prevent extension.
cation both of catheterization and of operative coronary perfusion.-'1 As indicated by Ross and Gorlin,7 the incidence of complications following coronary arteriography is higher in women than in men, and two of three deaths reported in the cooperative study were in women. Claudon and associates* reviewed the English literature and reported on 24 cases of "primary" coronary artery dissection (i.e., without antecedent instrumentation), 20 of which occurred in women. It is interesting that the reports of Ross and Gorlin7 and of Claudon's group both indicate that relatively young women with normal coronary arteries appear to be at greatest risk of coronary artery dissection. The importance of early operative repair is indicated by the high incidence of sudden death, usually within hours of the onset
Fig. 5. Angiogram of the vein graft obtained 6 months after the operation. The graft is widely patent with excellent flow to the recipient distal right coronary artery.
of symptoms. 7, " The visually apparent ischemia, obvious absence of blood flow in the distal right coronary artery, and the electrocardiographic evidence of impending infarction in our patient lend support to this conclusion. The value of preventing further extension of the medial dissection is obvious. We chose to do this by ligation of the artery at a point distal to the origin of dissection, although alternatively an end-toend anastomosis could be made between the vein graft and the distal artery. The fact that coronary artery dissection appears to occur more frequently in patients with otherwise normal vessels should promote an attitude of urgency in diagnosis and treatment and should suggest optimism with regard to prognosis. Conclusions 1. Medial dissection of a coronary artery can be a delayed complication of coronary angiography. 2. The group of patients who appear to be at greatest risk are relatively young women (40 years old or less) without significant preexisting coronary disease. 3. The natural course of untreated coronary artery dissection is usually fatal. 4. Therefore, the syndrome of status anginosus following coronary arteriography represents a diagnostic and therapeutic
Volume 69
Number 6
Coronary artery dissection after angiography
88 3
June, 1975
emergency in which every effort should be made to establish the diagnosis and institute definitive therapy rapidly. 5. The proximal end of the dissection should be identified and secured so as to obviate further dissection, either by ligation of the vessel at that point or by a circumferential anastomosis to the vein graft. REFERENCES 1 Judkins, M. P.: Selective Coronary Arteriography. I. A Percutaneous Transfemoral Technique, Radiology 89: 815, 1967. 2 Braunwald, E.: Death Related to Cardiac Catheterization, Circulation 37, 38: 17, 1968 (Suppl. III). 3 Kitamura, K., Gobel, F . L., and Wang, Y.: Dissection of the Left Coronary Artery Complicating Retrograde Left Heart Catheterization, Chest 57: 587, 1970.
4 Haas, J. M., Peterson, C. R., and Jones, R. C : Subintimal Dissection of the Coronary Arteries: A Complication of Selective Coronary Arteriography and the Transfemoral Percutaneous Approach, Circulation 38: 678, 1968. 5 Heilbrunn, A., and Zimmerman, J. M . : Coronary Artery Dissection: A Complication of Cannulation, J. THORAC. CARDIOVASC. SURG. 49:
767, 1965. 6 Bulkley, B. H., and Roberts, W. C : Isolated Coronary Arterial Dissection: A Complication of Cardiac Operations, J. THORAC. CARDIOVASC. SURG. 67: 148, 1974.
7 Ross, R. S., and Gorlin, R.: Coronary Arteriography, Circulation 37, 38: 67, 1968 (Suppl. III). 8 Claudon, D. G., Claudon, D. B., and Edwards, J. E.: Primary Dissecting Aneurysm of Coronary Artery, Circulation 45: 259, 1972.
Lynn H. Harrison, Jr., M.D., David L. Gregg, M.D., Samuel B. Itscoitz, M.D., David R. Redwood, M.D., and Lawrence L. Michaelis, M.D., Bethesda, Md.
.L/elayed coronary artery dissection is a well-known complication both of catheterization and of coronary perfusion. We recently performed an aorto-coronary artery bypass operation to correct this condition in a 44-year-old woman. To our knowledge, operative repair of this lesion has not previously been reported in the literature. Case report A 44-year-old woman was admitted to the National Heart and Lung Institute in January, 1974, for evaluation of atypical angina. She had experienced two episodes of exercise-related chest pain 18 months prior to admission and had been hospitalized 1 year earlier with electrocardiographic and enzyme changes suggesting an anterior myocardial infarction. After that hospitalization, she continued to have chest pain three to four times per week. The patient's father had died of a ruptured femoral artery aneurysm, her mother was hypertensive, and two of her five sisters had
From the Clinic of Surgery and the Cardiology Branch, National Heart and Lung Institute, Bethesda, Md. 20014. Received for publication Nov. 20, 1974. Address for reprints: Lawrence L. Michaelis, M.D., Clinic of Surgery, National Heart and Lung Institute, Bethesda, Md. 20014.
880
sustained myocardial infarctions in middle age, one sister dying at the age of 45 years of an acute infarction. The patient was postmenopausal and had a 20 pack-year history of smoking. Physical examination on admission was unremarkable. The electrocardiogram demonstrated left axis deviation with Q waves in Leads V, to Vj. Fasting serum cholesterol was 170 mg. Exercise testing did not provoke chest pain at a power output of 60 to 80 watts for 5 minutes. Left heart catheterization was performed, including coronary angiography. The left ventricular end-diastolic pressure was 7 mm. Hg, and the left ventricular cineangiogram demonstrated normal contractions. Coronary angiography was performed by percutaneous insertion of the catheter* into the femoral artery.' Coronary angiograms were originally interpreted as normal with a right dominant system (Fig. 1), although retrospective review revealed a small, nonstenotic intimal irregularity in the proximal right coronary artery (see arrow). Forty-eight hours after catheterization, and shortly after a roentgen examination with barium swallow, the patient experienced the sudden onset of crushing substernal chest pain associated with nausea, vomiting, and diaphoresis. The pain was not relieved by 0.4 mg. of nitroglycerine sublingually and 10 mg. of morphine sulfate. Cardiac examination revealed no new findings, but an electrocardiogram demonstrated marked ST-T-wave *Cordis Corp., Miami, Fla.
Volume 69
Number (>
Coronary artery dissection after angiography
881
June, 1975
Fig. 2. Right coronary arteriogram, obtained 45 minutes after the onset of pain, demonstrates a dissection beginning in the proximal portion of the vessel.
Fig. 1. Initial right coronary arteriogram (left anterior oblique projection). Retrospective review demonstrates an area of irregularity (arrow) in the proximal artery which likely represents the site at which dissection began.
changes consistent with diaphragmatic and subendocardial ischemia. Emergency repeat coronary angiography demonstrated a normal left coronary system. However, study of the dominant right system revealed marked changes from its previous appearance (Fig. 2) consistent with medial dissection throughout the entire vertical portion of the artery extending to the acute margin of the right ventricle. N o re-entry point was identified. Serial films showed residual contrast medium in the right coronary artery 30 minutes after injection (Fig. 3 ) . While in the catheterization laboratory, the patient developed ventricular fibrillation, but normal sinus rhythm was restored by countershock. She was taken directly to the operating room where a median sternotomy was performed and cardiopulmonary bypass instituted. Inspection of the heart revealed mottling and dyskinesia of the anterior surface of the right ventricle. The proximal right coronary artery was edematous and discolored, whereas the distal artery was collapsed and pallid. A saphenous vein bypass graft was inserted between the aorta and m i d right coronary artery, and the proximal vessel was Iigated at a point distal to the beginning of adventitial discoloration (Fig. 4 ) . The patient was weaned from cardiopulmonary bypass with ease.
Fig. 3. Thirty minutes after selective injection of the artery, residual contrast material remains in the false lumen of the dissection. We noted that the area of the right ventricle which had been ischemic prior to grafting was now pink and contracted well. The patient's postoperative course was benign, and she was discharged on the twelfth postoperative day. She has since been followed as an outpatient and remains well. Six months after the operation, angiography demonstrated a widely patent graft with excellent filling of the recipient right coronary artery (Fig. 5 ) . Left ventriculography revealed a hypokinetic inferior wall with a small zone of akinesia in its midportion.
Comment To our knowledge, operative repair of a delayed coronary artery dissection has not previously been reported, although this entity has been well documented as a compli-
The Journal of
8 82
Harrison et al.
Thoracic and Cardiovascular Surgery
=
\
Fig. 4. The operation consisted of saphenous vein bypass grafting from the aorta to the coronary artery distal to the dissection. The artery was ligated past the origin of dissection to prevent extension.
cation both of catheterization and of operative coronary perfusion.-'1 As indicated by Ross and Gorlin,7 the incidence of complications following coronary arteriography is higher in women than in men, and two of three deaths reported in the cooperative study were in women. Claudon and associates* reviewed the English literature and reported on 24 cases of "primary" coronary artery dissection (i.e., without antecedent instrumentation), 20 of which occurred in women. It is interesting that the reports of Ross and Gorlin7 and of Claudon's group both indicate that relatively young women with normal coronary arteries appear to be at greatest risk of coronary artery dissection. The importance of early operative repair is indicated by the high incidence of sudden death, usually within hours of the onset
Fig. 5. Angiogram of the vein graft obtained 6 months after the operation. The graft is widely patent with excellent flow to the recipient distal right coronary artery.
of symptoms. 7, " The visually apparent ischemia, obvious absence of blood flow in the distal right coronary artery, and the electrocardiographic evidence of impending infarction in our patient lend support to this conclusion. The value of preventing further extension of the medial dissection is obvious. We chose to do this by ligation of the artery at a point distal to the origin of dissection, although alternatively an end-toend anastomosis could be made between the vein graft and the distal artery. The fact that coronary artery dissection appears to occur more frequently in patients with otherwise normal vessels should promote an attitude of urgency in diagnosis and treatment and should suggest optimism with regard to prognosis. Conclusions 1. Medial dissection of a coronary artery can be a delayed complication of coronary angiography. 2. The group of patients who appear to be at greatest risk are relatively young women (40 years old or less) without significant preexisting coronary disease. 3. The natural course of untreated coronary artery dissection is usually fatal. 4. Therefore, the syndrome of status anginosus following coronary arteriography represents a diagnostic and therapeutic
Volume 69
Number 6
Coronary artery dissection after angiography
88 3
June, 1975
emergency in which every effort should be made to establish the diagnosis and institute definitive therapy rapidly. 5. The proximal end of the dissection should be identified and secured so as to obviate further dissection, either by ligation of the vessel at that point or by a circumferential anastomosis to the vein graft. REFERENCES 1 Judkins, M. P.: Selective Coronary Arteriography. I. A Percutaneous Transfemoral Technique, Radiology 89: 815, 1967. 2 Braunwald, E.: Death Related to Cardiac Catheterization, Circulation 37, 38: 17, 1968 (Suppl. III). 3 Kitamura, K., Gobel, F . L., and Wang, Y.: Dissection of the Left Coronary Artery Complicating Retrograde Left Heart Catheterization, Chest 57: 587, 1970.
4 Haas, J. M., Peterson, C. R., and Jones, R. C : Subintimal Dissection of the Coronary Arteries: A Complication of Selective Coronary Arteriography and the Transfemoral Percutaneous Approach, Circulation 38: 678, 1968. 5 Heilbrunn, A., and Zimmerman, J. M . : Coronary Artery Dissection: A Complication of Cannulation, J. THORAC. CARDIOVASC. SURG. 49:
767, 1965. 6 Bulkley, B. H., and Roberts, W. C : Isolated Coronary Arterial Dissection: A Complication of Cardiac Operations, J. THORAC. CARDIOVASC. SURG. 67: 148, 1974.
7 Ross, R. S., and Gorlin, R.: Coronary Arteriography, Circulation 37, 38: 67, 1968 (Suppl. III). 8 Claudon, D. G., Claudon, D. B., and Edwards, J. E.: Primary Dissecting Aneurysm of Coronary Artery, Circulation 45: 259, 1972.