Healing of Iatrogenic Coronary Dissection and Intramural Hematoma: Insights From OCT

J INVASIVE CARDIOL 2018;30(1):E12-E13.

Key words: coronary artery dissection, optical coherence tomography, iatrogenic coronary dissection

A 57-year-old female presented with Canadian Cardiovascular Society class 2 angina and a positive stress test. Angiography was performed via right radial approach with a 5 Fr Tiger catheter (Terumo) (Figure 1). The artery had to be re-engaged for the right anterior oblique projection, resulting in spiral dissection and Thrombolysis in Myocardial Infarction (TIMI) 0 flow. The ostium and likely entry point of the dissection (3.5 x 28 mm Xience drug-eluting stent [DES]; Abbott Vascular) and mid vessel stenosis (3.0 x 28 mm Xience DES) were both stented, restoring TIMI 3 flow. There was intramural hematoma throughout the remaining right coronary artery (RCA). We thought the dissection ended at the crux, so this was stented (3.0 x 15 mm Xience DES) to further secure the RCA. However, following this we performed optical coherence tomography (Video 1), which showed dissection throughout the posterior left ventricular branch (PLB) and confirmed the long segment of intramural hematoma in the stent gap. The patient was pain free and flow was normal, so the case was ended. Repeat optical coherence tomography at 3 months (Figure 1, Video 2) showed complete healing of the PLB and a small amount of residual intramural hematoma.

Catheter dissections are a rare but serious complication of coronary angiography.¹ Optical coherence tomography can successfully guide both PCI and conservative management in cases of catheter-induced dissection.^2,3 Sealing the entry point with PCI appears to avoid the need for surgical revascularization.^1,3 Our imaging supports a natural history of healing in iatrogenic dissection if the entry site is sealed and flow is restored.

Watch the associated Video Series here.

References

1.    Eshtehardi P, Adorjan P, Togni M, et al. Iatrogenic left main coronary artery dissection: incidence, classification, management, and long-term follow-up. Am Heart J. 2010;159:1147-1153.

2.    Barber-Chamoux N, Souteyrand G, Combaret N, Ouedraogo E, Lusson JR, Motreff P. Contribution of optical coherence tomography imaging in management of iatrogenic coronary dissection. Cardiovasc Revasc Med. 2016;17:138-142.

3.    Binder RK, Boone RH, Webb JG. Left main dissection conservatively managed with optical coherence tomography guidance. Catheter Cardiovasc Interv. 2014;83:65-68.

From the ¹Department of Cardiology, London Health Sciences Centre, London, Ontario, Canada; and ²Schulich School of Medicine, University of Western Ontario, London, Ontario, Canada.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

Manuscript accepted June 2, 2017. 

Address for correspondence: Sam Hayman, MBBS, MSc, FRACP, HeartCare Partners, Mater Private Clinic, 550 Stanley Street, South Brisbane, QLD 4101, Australia. Email: SHayman@heartcarepartners.com.au