Coronary Access After Ascending Aorta Repair
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J INVASIVE CARDIOL 2024. doi:10.25270/jic/24.00348. Epub December 30, 2024.
A 27-year-old man with uncontrolled hypertension presented with a type A aortic dissection involving the ascending, arch, and descending aorta, aneurysmal severe dilatation of the descending aorta, and hemopericardium concerning for aortic rupture and cardiac tamponade (Video).
The patient underwent ascending aorta replacement with a 28-mm tube graft as well as debranching of the innominate artery and left carotid artery using a trifurcating graft connected to the medial side of the mid-ascending aorta just cranial to the sinotubular junction (Figure A and B). Residual dissection in the arch was noted but not addressed during the initial surgery with plans for repair of the arch and descending aorta within 3 months. There was no time to perform coronary evaluation prior to the emergency surgery; however, intraoperatively, significant coronary calcification of the LAD was noted. The left ventricle had no wall motion abnormalities, and the patient recovered from the first surgery uneventfully.
Before the second surgery, coronary angiogram was required to address any coronary artery disease. Vascular access was limited due to the complex dissection of the descending aorta and the distal aortic arch (Figure C), necessitating a right radial artery approach.
Despite ultrasound guidance, the right radial artery was too small to wire, leading to the use of a distal right radial artery approach. A 5-French (Fr) sheath and a 5-Fr Tiger diagnostic catheter were used. The catheter successfully engaged both the right and left coronary arteries, navigating through the trifurcating graft into the proximal ascending aortic graft that opened just distal to the sinus of Valsalva. The patient was found to have non-obstructive coronary artery disease.
Our case demonstrates how a single-catheter radial approach can be utilized to navigate the aorta and access the coronaries after surgical repair of a complex dissection, despite the challenges posed by dissection-related vascular access issues.
Affiliations and Disclosures
Rimmy Farrakhan, MD1; Puja Parikh, MD1; John P. Reilly, MD1; Maroun Yammine, MD2; On Chen, MD1
From the Divisions of 1Cardiology and 2Cardiothoracic Surgery, Stony Brook University Hospital, Stony Brook, New York.
Disclosures: The authors report no financial relationships or conflicts of interest regarding the content herein.
Consent statement: The authors confirm that informed consent was obtained from the patient for the intervention described in the manuscript and to the publication of this case.
Address for correspondence: Rimmy Farrakhan, MD; 3302 Mill Rd. Ronkonkoma, NY 11779, USA. Email: rimmy.p.garg@gmail.com; X: @RimmyGarg
