(cid:56)(cid:74)(cid:74)(cid:5)(cid:73)(cid:78)(cid:88)(cid:72)(cid:90)(cid:88)(cid:88)(cid:78)(cid:84)(cid:83)(cid:88)(cid:17)(cid:5)(cid:88)(cid:89)(cid:70)(cid:89)(cid:88)(cid:17)(cid:5)(cid:70)(cid:83)(cid:73)(cid:5)(cid:70)(cid:90)(cid:89)(cid:77)(cid:84)(cid:87)(cid:5)(cid:85)(cid:87)(cid:84)(cid:75)(cid:78)(cid:81)(cid:74)(cid:88)(cid:5)(cid:75)(cid:84)(cid:87)(cid:5)(cid:89)(cid:77)(cid:78)(cid:88)(cid:5)(cid:85)(cid:90)(cid:71)(cid:81)(cid:78)(cid:72)(cid:70)(cid:89)(cid:78)(cid:84)(cid:83)(cid:5)(cid:70)(cid:89)(cid:31)(cid:5)(cid:77)(cid:89)(cid:89)(cid:85)(cid:88)(cid:31)(cid:20)(cid:20)(cid:92)(cid:92)(cid:92)(cid:19)(cid:87)(cid:74)(cid:88)(cid:74)(cid:70)(cid:87)(cid:72)(cid:77)(cid:76)(cid:70)(cid:89)(cid:74)(cid:19)(cid:83)(cid:74)(cid:89)(cid:20)(cid:85)(cid:90)(cid:71)(cid:81)(cid:78)(cid:72)(cid:70)(cid:89)(cid:78)(cid:84)(cid:83)(cid:20)(cid:27)(cid:28)(cid:28)(cid:30)(cid:21)(cid:23)(cid:30)
`
`(cid:38)(cid:68)(cid:87)(cid:75)(cid:72)(cid:87)(cid:72)(cid:85)(cid:16)(cid:76)(cid:81)(cid:71)(cid:88)(cid:70)(cid:72)(cid:71)(cid:3)(cid:70)(cid:82)(cid:85)(cid:82)(cid:81)(cid:68)(cid:85)(cid:92)(cid:3)(cid:68)(cid:85)(cid:87)(cid:72)(cid:85)(cid:92)(cid:3)(cid:71)(cid:76)(cid:86)(cid:86)(cid:72)(cid:70)(cid:87)(cid:76)(cid:82)(cid:81)(cid:29)(cid:3)(cid:53)(cid:76)(cid:86)(cid:78)(cid:3)(cid:73)(cid:68)(cid:70)(cid:87)(cid:82)(cid:85)(cid:86)(cid:15)(cid:3)(cid:83)(cid:85)(cid:72)(cid:89)(cid:72)(cid:81)(cid:87)(cid:76)(cid:82)(cid:81)(cid:3)(cid:68)(cid:81)(cid:71)
`(cid:80)(cid:68)(cid:81)(cid:68)(cid:74)(cid:72)(cid:80)(cid:72)(cid:81)(cid:87)
`
`(cid:38)(cid:87)(cid:89)(cid:78)(cid:72)(cid:81)(cid:74)(cid:100)(cid:100)(cid:78)(cid:83)(cid:100)(cid:100)(cid:57)(cid:77)(cid:74)(cid:5)(cid:47)(cid:84)(cid:90)(cid:87)(cid:83)(cid:70)(cid:81)(cid:5)(cid:84)(cid:75)(cid:5)(cid:78)(cid:83)(cid:91)(cid:70)(cid:88)(cid:78)(cid:91)(cid:74)(cid:5)(cid:72)(cid:70)(cid:87)(cid:73)(cid:78)(cid:84)(cid:81)(cid:84)(cid:76)(cid:94)(cid:5)(cid:123)(cid:5)(cid:51)(cid:84)(cid:91)(cid:74)(cid:82)(cid:71)(cid:74)(cid:87)(cid:5)(cid:23)(cid:21)(cid:21)(cid:27)
`
`(cid:56)(cid:84)(cid:90)(cid:87)(cid:72)(cid:74)(cid:31)(cid:5)(cid:53)(cid:90)(cid:71)(cid:50)(cid:74)(cid:73)
`
`(cid:40)(cid:46)(cid:57)(cid:38)(cid:57)(cid:46)(cid:52)(cid:51)(cid:56)
`(cid:26)(cid:22)
`
`(cid:25)(cid:5)(cid:70)(cid:90)(cid:89)(cid:77)(cid:84)(cid:87)(cid:88)(cid:17)(cid:5)(cid:78)(cid:83)(cid:72)(cid:81)(cid:90)(cid:73)(cid:78)(cid:83)(cid:76)(cid:31)
`
`(cid:38)(cid:83)(cid:73)(cid:87)(cid:74)(cid:92)(cid:5)(cid:39)(cid:84)(cid:94)(cid:81)(cid:74)
`(cid:58)(cid:83)(cid:78)(cid:91)(cid:74)(cid:87)(cid:88)(cid:78)(cid:89)(cid:94)(cid:5)(cid:84)(cid:75)(cid:5)(cid:51)(cid:74)(cid:92)(cid:72)(cid:70)(cid:88)(cid:89)(cid:81)(cid:74)
`
`(cid:22)(cid:29)(cid:28)(cid:5)(cid:53)(cid:58)(cid:39)(cid:49)(cid:46)(cid:40)(cid:38)(cid:57)(cid:46)(cid:52)(cid:51)(cid:56)(cid:100)(cid:100)(cid:100)(cid:24)(cid:17)(cid:25)(cid:29)(cid:27)(cid:5)(cid:40)(cid:46)(cid:57)(cid:38)(cid:57)(cid:46)(cid:52)(cid:51)(cid:56)(cid:100)(cid:100)(cid:100)
`
`(cid:56)(cid:42)(cid:42)(cid:5)(cid:53)(cid:55)(cid:52)(cid:43)(cid:46)(cid:49)(cid:42)
`
`(cid:55)(cid:42)(cid:38)(cid:41)(cid:56)
`(cid:23)(cid:17)(cid:30)(cid:24)(cid:28)
`
`(cid:47)(cid:84)(cid:83)(cid:5)(cid:55)(cid:5)(cid:55)(cid:74)(cid:88)(cid:70)(cid:87)
`(cid:47)(cid:84)(cid:77)(cid:83)(cid:88)(cid:5)(cid:45)(cid:84)(cid:85)(cid:80)(cid:78)(cid:83)(cid:88)(cid:5)(cid:50)(cid:74)(cid:73)(cid:78)(cid:72)(cid:78)(cid:83)(cid:74)
`
`(cid:22)(cid:21)(cid:30)(cid:5)(cid:53)(cid:58)(cid:39)(cid:49)(cid:46)(cid:40)(cid:38)(cid:57)(cid:46)(cid:52)(cid:51)(cid:56)(cid:100)(cid:100)(cid:100)(cid:24)(cid:17)(cid:27)(cid:25)(cid:26)(cid:5)(cid:40)(cid:46)(cid:57)(cid:38)(cid:57)(cid:46)(cid:52)(cid:51)(cid:56)(cid:100)(cid:100)(cid:100)
`
`(cid:56)(cid:42)(cid:42)(cid:5)(cid:53)(cid:55)(cid:52)(cid:43)(cid:46)(cid:49)(cid:42)
`
`(cid:56)(cid:84)(cid:82)(cid:74)(cid:5)(cid:84)(cid:75)(cid:5)(cid:89)(cid:77)(cid:74)(cid:5)(cid:70)(cid:90)(cid:89)(cid:77)(cid:84)(cid:87)(cid:88)(cid:5)(cid:84)(cid:75)(cid:5)(cid:89)(cid:77)(cid:78)(cid:88)(cid:5)(cid:85)(cid:90)(cid:71)(cid:81)(cid:78)(cid:72)(cid:70)(cid:89)(cid:78)(cid:84)(cid:83)(cid:5)(cid:70)(cid:87)(cid:74)(cid:5)(cid:70)(cid:81)(cid:88)(cid:84)(cid:5)(cid:92)(cid:84)(cid:87)(cid:80)(cid:78)(cid:83)(cid:76)(cid:5)(cid:84)(cid:83)(cid:5)(cid:89)(cid:77)(cid:74)(cid:88)(cid:74)(cid:5)(cid:87)(cid:74)(cid:81)(cid:70)(cid:89)(cid:74)(cid:73)(cid:5)(cid:85)(cid:87)(cid:84)(cid:79)(cid:74)(cid:72)(cid:89)(cid:88)(cid:31)
`
`(cid:53)(cid:87)(cid:74)(cid:91)(cid:70)(cid:81)(cid:74)(cid:83)(cid:72)(cid:74)(cid:5)(cid:84)(cid:75)(cid:5)(cid:81)(cid:84)(cid:92)(cid:5)(cid:59)(cid:78)(cid:89)(cid:70)(cid:82)(cid:78)(cid:83)(cid:5)(cid:41)(cid:5)(cid:78)(cid:83)(cid:5)(cid:70)(cid:72)(cid:90)(cid:89)(cid:74)(cid:5)(cid:82)(cid:94)(cid:84)(cid:72)(cid:70)(cid:87)(cid:73)(cid:78)(cid:70)(cid:81)(cid:5)(cid:78)(cid:83)(cid:75)(cid:70)(cid:87)(cid:72)(cid:89)(cid:78)(cid:84)(cid:83)(cid:5)(cid:70)(cid:83)(cid:73)(cid:5)(cid:88)(cid:74)(cid:91)(cid:74)(cid:87)(cid:74)(cid:5)(cid:72)(cid:70)(cid:87)(cid:73)(cid:78)(cid:84)(cid:91)(cid:70)(cid:88)(cid:72)(cid:90)(cid:81)(cid:70)(cid:87)(cid:5)(cid:73)(cid:78)(cid:88)(cid:74)(cid:70)(cid:88)(cid:74)(cid:5)(cid:59)(cid:78)(cid:74)(cid:92)(cid:5)(cid:85)(cid:87)(cid:84)(cid:79)(cid:74)(cid:72)(cid:89)
`
`(cid:45)(cid:74)(cid:70)(cid:87)(cid:89)(cid:5)(cid:43)(cid:70)(cid:78)(cid:81)(cid:90)(cid:87)(cid:74)(cid:5)(cid:84)(cid:90)(cid:89)(cid:72)(cid:84)(cid:82)(cid:74)(cid:88)(cid:5)(cid:59)(cid:78)(cid:74)(cid:92)(cid:5)(cid:85)(cid:87)(cid:84)(cid:79)(cid:74)(cid:72)(cid:89)
`
`(cid:38)(cid:81)(cid:81)(cid:5)(cid:72)(cid:84)(cid:83)(cid:89)(cid:74)(cid:83)(cid:89)(cid:5)(cid:75)(cid:84)(cid:81)(cid:81)(cid:84)(cid:92)(cid:78)(cid:83)(cid:76)(cid:5)(cid:89)(cid:77)(cid:78)(cid:88)(cid:5)(cid:85)(cid:70)(cid:76)(cid:74)(cid:5)(cid:92)(cid:70)(cid:88)(cid:5)(cid:90)(cid:85)(cid:81)(cid:84)(cid:70)(cid:73)(cid:74)(cid:73)(cid:5)(cid:71)(cid:94)(cid:5)(cid:38)(cid:83)(cid:73)(cid:87)(cid:74)(cid:92)(cid:5)(cid:39)(cid:84)(cid:94)(cid:81)(cid:74)(cid:5)(cid:84)(cid:83)(cid:5)(cid:22)(cid:28)(cid:5)(cid:50)(cid:70)(cid:87)(cid:72)(cid:77)(cid:5)(cid:23)(cid:21)(cid:22)(cid:28)(cid:19)
`
`(cid:57)(cid:77)(cid:74)(cid:5)(cid:90)(cid:88)(cid:74)(cid:87)(cid:5)(cid:77)(cid:70)(cid:88)(cid:5)(cid:87)(cid:74)(cid:86)(cid:90)(cid:74)(cid:88)(cid:89)(cid:74)(cid:73)(cid:5)(cid:74)(cid:83)(cid:77)(cid:70)(cid:83)(cid:72)(cid:74)(cid:82)(cid:74)(cid:83)(cid:89)(cid:5)(cid:84)(cid:75)(cid:5)(cid:89)(cid:77)(cid:74)(cid:5)(cid:73)(cid:84)(cid:92)(cid:83)(cid:81)(cid:84)(cid:70)(cid:73)(cid:74)(cid:73)(cid:5)(cid:75)(cid:78)(cid:81)(cid:74)(cid:19)
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`Review
`
`Catheter-Induced Coronary Artery Dissection: Risk Factors,
`Prevention and Management
`
`Andrew J. Boyle, MBBS, PhD, Michael Chan, MD, Joud Dib, MD, Jon Resar, MD
`
`ABSTRACT: Guide catheter-induced
`dissection of the coronary arteries is an
`uncommon but potentially catastrophic
`complication of diagnostic and intervention-
`al cardiac catheterization. Several factors
`placing the individual at higher risk of this
`complication have been identified. We dis-
`cuss these risk factors and utilize them to
`propose methods to prevent dissections.
`Management options of coronary artery dis-
`section are also discussed.
`J INVASIVE CARDIOL
`2006;18:500–503
`
`Figure 1. Catheter-induced dissection of the right coronary artery. (A) Diagnostic angiogram
`demonstrates a 90% lesion in the RCA (arrow). (B) Extensive dissection of the RCA antegrade
`from the catheter results in occlusion in the mid-RCA. A wire is seen distally in the vessel, but it
`cannot be determined if the wire is in the true lumen or false lumen. (C) Contrast injection
`through an over-the-wire balloon confirms the position of the balloon catheter in the true lumen.
`(D) Extensive stenting of the artery restores patency and TIMI-3 flow.
`
`Catheter-induced coronary artery
`dissection is an uncommon complica-
`tion of percutaneous coronary interven-
`tion and cardiac catheterization, but
`when it occurs, the outcomes can be
`devastating. The exact incidence
`remains unknown, with some suggesting
`it may be underreported.1 There are
`numerous reports of retrograde dissec-
`tion into the aortic root in the literature,
`as this subgroup appears to capture the
`imagination more than the more com-
`mon antegrade dissections. However,
`the outcomes of antegrade coronary
`artery dissection caused by coronary
`catheters can also be catastrophic. Still,
`there remains a paucity of data regarding
`the incidence, risk factors and manage-
`ment of iatrogenic catheter-induced dissection of coronary
`arteries per se. Additionally, the natural history of catheter-
`induced coronary artery dissection is incompletely described,
`but published reports describe varied outcomes. The choice
`of treatment, therefore, when confronted with catheter-
`induced coronary artery dissection, is currently made on a
`case-by-case basis, with no evidence-based guidelines to assist
`the operator. We present a case of catheter-induced coronary
`dissection and review the risk factors for this complication in
`
`From Johns Hopkins University School of Medicine, Baltimore, Maryland.
`The authors report no conflicts of interest regarding the content herein.
`Manuscript submitted April 3, 2006 and accepted June 30, 2006.
`Address for correspondence: Jon R. Resar, MD, Director of Interventional Car-
`diology, Johns Hopkins School of Medicine, Division of Cardiology, 600 North
`Wolfe Street, Blalock 524, Baltimore, MD, 21287. E-mail: jresar@jhmi.edu
`
`order to highlight methods to avoid its occurrence. We also dis-
`cuss the literature on management options when it does occur.
`
`Case Presentation
`A61-year-old male with a history of dyslipidemia and gas-
`troesophageal reflux disease was admitted with unstable angina.
`Cardiac catheterization showed a 90% proximal left anterior
`descending (LAD) coronary artery stenosis and a right coronary
`artery (RCA) proximal 90% stenosis and mid-vessel 50% steno-
`sis (Figure 1A). Two-vessel percutaneous coronary intervention
`(PCI) was the preferred treatment strategy. The LAD was treat-
`ed with angioplasty and stenting, which was uncomplicated. The
`RCA was engaged with a 6 Fr Launcher Judkins Right 4 (JR4)
`guiding catheter (Medtronic, Inc., Minneapolis, Minnesota)
`which was unable to gain adequate engagement, and so was
`changed for a 6 Fr Launcher Noto guide catheter (Medtronic).
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`The first fluoroscopic test injection demonstrated a spiral dissec-
`tion from the catheter to the mid-RCA where there was occlusion
`of flow, and the patient suddenly complained of severe chest pain.
`There was ST-segment elevation in the inferior leads of the electro-
`cardiogram (ECG). A Luge™ soft-tip guidewire (Boston Scientific
`Corp., Natick, Massachusetts) was rapidly inserted, and a
`Maverick®2.5 x 9 mm over-the-wire balloon catheter (Boston Sci-
`entific) was advanced into the artery to beyond the occlusion
`(Figure 1B). Position within the true lumen was confirmed by
`contrast injection through the balloon catheter (Figure 1C). The
`artery was stented with 3 Cypher®sirolimus-eluting stents (Cordis
`Corp., Miami, Florida) 2.5 x 28 mm, 2.75 x 33 mm and 3.0 x
`33 mm from the distal to proximal segments. The procedural
`result was excellent with TIMI-3 flow distally, no residual steno-
`sis and resolution of the patient’s chest pain and ECG changes
`(Figure 1D). There was no postprocedural cardiac enzyme eleva-
`tion, and the patient was discharged the following day.
`
`Discussion
`The incidence of iatrogenic coronary artery dissection at
`the time of cardiac catheterization or percutaneous coronary
`intervention is not known. Catheter-induced dissection with
`retrograde extension to the aortic root, a feared complication
`of cardiac catheterization, is rare and has been estimated to
`occur in approximately 0.008 to 0.02% of diagnostic
`catheterizations and 0.06 to 0.07% of percutaneous coronary
`interventions,2,3 but the overall incidence of catheter-induced
`dissections remains unknown. The natural history of coro-
`nary artery dissections is varied. In some cases, dissections
`lead to acute closure of the vessel with resultant myocardial
`infarction.4 In other circumstances, retrograde extension of
`the dissection back to involve the aorta can occur,5,6 and in
`some cases, dissections of the coronary artery have been asso-
`ciated with persistently normal (TIMI-3) flow into the distal
`arterial bed, with no damage to the heart muscle, and have
`healed without any intervention.7 It is this wide variety of
`potential clinical outcomes that hampers attempts to stan-
`dardize treatment for iatrogenic coronary artery dissections. It
`is critical, therefore, that each clinical scenario is evaluated on
`its own merits. A number of features mandate immediate
`revascularization, but in other situations, an expectant
`approach can be considered. We discuss the salient features of
`catheter-induced coronary artery dissection and propose an
`approach to this clinical situation.
`Risk factors for catheter-induced coronary artery dis-
`section. A number of factors are associated with increased
`risk for coronary artery dissection:
`1. Left main disease. Left main disease has been demon-
`strated as a risk factor for catheter-induced dissection, as well
`as being associated with poor outcomes. Devlin and colleagues
`detailed the association of left main disease, and even left main
`calcification in the absence of visible atherosclerosis and
`catheter-induced dissection of the left main coronary artery.8
`In the same series, 14 of the 20 left main dissections were due
`to contact of the catheter with the plaque. This highlights the
`importance of using catheters that are appropriately sized,
`positioned and coaxially aligned with the artery.
`
`Catheter-Induced Dissection
`
`2. The use of Amplatz-shaped catheters.6
`3. Catheterization for acute myocardial infarction.6
`Possible, but not definite, factors that have been suggested
`to increase the likelihood of coronary artery dissection include:
`1. Catheter manipulations.9
`2. Vigorous contrast injection.4
`3. Deep intubations of the catheter within the coronary
`artery.9
`4. Variant anatomy of the coronary ostia.10
`5. Vigorous, deep inspiration.11
`Prevention of catheter-induced coronary artery dissec-
`tion. Some of the above factors are modifiable, such as choice
`of guide catheter and handling techniques, whereas others can-
`not be altered, such as acute myocardial infarction. In these
`cases, awareness of the potential risk may aid in rapid recogni-
`tion of complications, and therefore potentially improve the
`speed with which definitive therapy may be instituted.
`We recommend using appropriately sized and shaped
`catheters to avoid the contrast injection being directed at a
`plaque. Initial contrast injections should not be forceful until
`correct coaxial alignment of the catheter has been demon-
`strated. Contrast should not be injected if the pressure is
`damped, as this may be due to the catheter resting against a
`plaque in the artery. Finally, the choice of guide catheter is a
`risk-benefit tradeoff between extra backup and the possibility
`of deep intubation and subsequent coronary artery dissection.
`This decision must be at the operator’s discretion and must
`be made on a case-by-case basis, however, the operator
`should be aware of the possibility of dissection when using
`more aggressive guide catheters.
`Management of catheter-induced coronary artery dissec-
`tion. The outcomes of coronary artery dissection, and therefore
`the management of the condition, depend on the patency of the
`distal vessel and the extent of propagation of the dissection. If
`there is compromise to the distal artery bed, such as acute closure
`of the artery, urgent revascularization is mandated to prevent
`infarction of that myocardial territory. This may be achieved by
`percutaneous coronary intervention (PCI) or coronary artery
`bypass graft (CABG) surgery, and the decision on which revas-
`cularization method is used must be at the discretion of the oper-
`ators. There have been reports of successful outcomes with
`coronary artery stenting,9,12,13 and CABG.4,14,15 Similarly, even in
`the absence of acute vessel closure, if there is any suggestion of
`myocardial ischemia, such as new ECG changes or chest pain,
`urgent revascularization should also be undertaken to prevent
`myocardial infarction, as myocardial infarction may be seen even
`with TIMI-2 or -3 flow.3 However, if the vessel remains patent,
`but a dissection is seen angiographically without obstruction to
`flow, then the therapeutic options are less clear. Conservative
`management of guide catheter-induced coronary artery dissec-
`tion has met with successful outcomes in selected patients.4,7 The
`choice of stenting versus conservative management is therefore
`made on a case-by-case basis.
`The extent of propagation of the dissection may alter
`management decisions. Dissections may remain localized, or
`they may extend in the antegrade or retrograde directions, or
`
`Vol. 18, No. 10, October 2006
`
`501
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`BOYLE, et al.
`
`Dissection recognized
`
`Consider IABP insertion
`
`Advance soft-tip wire
`into true lumen
`
`Confirm intraluminal
`position with OTW
`balloon
`
`Intraluminal
`
`False lumen
`
`Stent distal-to-
`proximal
`
`Rewire into true
`lumen
`
`Retrograde propagation
`to ascending aorta?
`
`Unable to access
`true lumen
`
`Emergency
`CABG
`
`No
`
`Yes
`
`Extensive dissection,
`hemodynamic
`instability, ischemia?
`
`No
`
`Yes
`
`Emergency surgery
`
`Perform ancillary imaging (CT, TEE, MRI)
`to define extent of dissection
`
`Consider surgery or observation
`
`Figure 2. Algorithm for risk assessment and treatment of guide catheter-induced coronary artery dissection.
`
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`both. Localized dissection flaps have been successfully treated
`conservatively,4 although others have described aggressive
`healing of these dissections, resulting in scar formation
`obstructing coronary flow.16 There may, therefore, be some
`benefit to more definitive revascularization therapy at the
`time the dissection occurs in order to prevent this late steno-
`sis. However, in this situation, there is not enough evidence
`to guide therapy, and the decision must be made individually
`for each patient, taking into account the risk of the procedure
`and subsequent antiplatelet therapy, versus the risks of treat-
`ing the patient medically.
`Extensive antegrade dissection can result in acute vessel
`closure and infarction of the vascular territory supplied by
`that artery. These dissections can often be treated by percu-
`taneous intervention and, therefore, most operators would
`advocate that antegrade dissections be treated with PCI as
`soon as they are recognized. Soft-tip wires should be used
`to carefully attempt to access the true lumen,12,17 and con-
`trast should be injected through an over-the-wire balloon
`to confirm location in the true lumen. If the initial attempt
`fails and enters the false lumen, another soft-tip wire
`should be carefully manipulated into the true lumen.17
`Consideration should be given to insertion of an intra-aor-
`tic balloon pump (IABP). If there is any delay in restora-
`tion of flow, the cardiac surgeons should be consulted
`regarding urgent bypass surgery.
`If there is retrograde propagation of the dissection to
`involve the aortic wall, the extent to which the aorta or its
`branches are involved will dictate the immediate manage-
`ment. Aorto-coronary dissections can remain localized to the
`sinus of Valsalva, or may extend into the ascending aorta.2,3,18
`They have even been described to extend to the aortic bifur-
`cation.19 It has been recommended that cases of localized
`aorto-coronary dissection not complicated by ischemia or
`hemodynamic instability can be managed conservatively.1
`However, if ischemia of any of the aortic branches occurs, if
`there is extensive dissection or if there is hemodynamic insta-
`bility, urgent surgery is the treatment of choice. Retrograde
`dissection involving the aorta should be assessed on clinical
`grounds and by urgent transesophageal echocardiography in
`the catheterization laboratory or by urgent computed tomog-
`raphy scan. It is reasonable to attempt to seal the entry site of
`the dissection with PCI and stenting first, and then the
`extent of dissection can be assessed. A cardiac surgical opin-
`ion should be sought early. Any ischemia, hemodynamic
`compromise or extensive dissection should prompt immedi-
`ate treatment with surgical repair of the aortic dissection.
`However, in the absence of these high-risk features, class I or
`II dissections may be managed conservatively.
`A proposal has been made by Dunning and colleagues6
`for a classification system based upon the extent of aortic
`
`Catheter-Induced Dissection
`
`involvement: Class 1: the contrast staining involves only the
`coronary cusp; Class II: contrast extends up the aortic wall
`< 40 mm; Class III: contrast extends > 40 mm up the aortic
`wall. In their series, the extent of propagation of aortic dis-
`section yielded prognostic information, with Class III dis-
`sections having uniformly poor outcomes. This classification
`may be useful for risk stratification.
`We propose, in Figure 2, a management protocol for
`catheter-induced coronary artery dissection that takes into
`account the few known high-risk features and prognostic
`indicators to guide management. Hopefully, with careful
`attention to avoid known predisposing factors, this complica-
`tion can be avoided where possible and, if encountered, can
`be managed in an appropriate and timely manner.
`
`References
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`Vol. 18, No. 10, October 2006
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