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Incidence, Treatment and Outcomes of Coronary Artery Dissection During Percutaneous Coronary Intervention
Abstract
Background. Coronary artery dissection is a feared and potentially life-threatening complication of percutaneous coronary intervention (PCI). Methods. We examined the clinical, angiographic, and procedural characteristics, and outcomes of coronary dissection at a tertiary care institution. Results. Between 2014 and 2019, unplanned coronary dissection occurred in 141 of 10,278 PCIs (1.4%). Median patient age was 68 (60, 78) years, 68% were men, and 83% had hypertension. The prevalence of diabetes (29%), and prior PCI (37%) was high. Most target vessels were significantly diseased: 48% had moderate/severe tortuosity and 62% had moderate/severe calcification. The most common cause of dissection was guidewire advancement (30%), followed by stenting (22%), balloon angioplasty (20%), and guide-catheter engagement (18%). TIMI flow was 0 in 33% and 1-2 in 41% of cases. Intravascular imaging was used in 17% of the cases. Stenting was used to treat the dissection in 73% of patients. There was no consequence of dissection in 43% of patients. Technical and procedural success was 65% and 55%, respectively. In-hospital major adverse cardiovascular events occurred in 23% of patients: 13 (9%) had an acute myocardial infarction (MI), 3 (2%) had emergency coronary artery bypass graft surgery, and 10 (7%) died. During a mean follow up of 1612 days, 28 (20%) patients died, and the rate of target lesion revascularization was 11.3% (n=16). Conclusion. Coronary artery dissection is an infrequent complication of PCI, but is associated with adverse clinical outcomes, such as death and acute MI.
J INVASIVE CARDIOL 2023;35(7):E341-E354. doi: 10.25270/jic/23.00007. Epub 2023 May 16.
Key words: percutaneous coronary intervention, complications, coronary artery dissection
Coronary artery dissection is an infrequent complication of percutaneous coronary intervention (PCI), but it can lead to severe, potentially life-threatening, events.1,2 Risk factors for coronary dissection include severe calcification and tortuosity, and iatrogenic factors such as use of guide catheter extensions, ballooning, and stenting.3,4 In the present study, we describe the incidence, treatment, and outcomes associated with coronary dissection at a tertiary care center.
Methods
We examined the clinical, angiographic, and procedural characteristics, and outcomes of 141 PCIs complicated by unplanned coronary dissection among 10,278 PCIs performed between 2014 and 2019 at a tertiary care institution. Data collection was recorded retrospectively, using a dedicated online database (Prospective Global Registry for the Study of Complications – PROGRESS-Complications, NCT05100940). The data were managed using REDCap (Research Electronic Data Capture) electronic data capture tools hosted at Minneapolis Heart Institute Foundation.5,6 The study was approved by the institutional review board.
Coronary CTOs were defined as coronary lesions with TIMI (Thrombolysis in Myocardial Infarction) grade 0 flow for < 3 months duration. The duration was estimated clinically, based on the first onset of angina, history of MI in the target vessel, or through comparison with a prior angiogram.7 Calcification and tortuosity were categorized through angiography as mild, moderate, or severe. Moderate calcification was defined as involving ≤ 50% of the reference lesion diameter and severe calcification was defined as involving > 50% of the reference lesion diameter. Moderate proximal vessel tortuosity was defined as the presence of at least 2 bends >70˚ or 1 bend > 90˚ and severe tortuosity as 2 bends > 90˚ in the target vessel.
Technical success was defined as <30% residual stenosis within the target segment and restoration of TIMI grade 3 flow. Procedural success was defined as the achievement of technical success in addition to no occurrence of in-hospital major adverse cardiac events (MACE). In-hospital MACE included any of the following: death, MI, recurrent symptoms requiring urgent repeat target-vessel revascularization with PCI or coronary artery bypass graft surgery (CABG), tamponade requiring either pericardiocentesis or surgery, and stroke. MI was defined using the Third Universal Definition of Myocardial Infarction (type 4 MI).8
Categorical variables were expressed as percentages and compared using Pearson’s chi-square test or Fisher’s exact test, as appropriate. Continuous variables were presented as mean ± standard deviation or median (interquartile range [IQR]) unless otherwise specified and were compared using the student’s t-test or Wilcoxon rank-sum test, as appropriate. All statistical analyses were performed using R, version 4.0.4 (R Foundation for Statistical Computing, Vienna, Austria). A P-value <.05 was considered statistically significant.
Results
Between 2014 and 2019, coronary dissection occurred in 141 of 10,278 PCIs (1.4%) performed at our center with no significant change over time (Figure 1). The baseline clinical and angiographic characteristics of the dissection patients are outlined in Table 1. Median patient age was 68 (60, 78) years, 68% were men, and 83% had hypertension. The prevalence of diabetes (29%) and prior PCI (37%) was high. The most common indications for PCI were symptom relief (31%) and non-ST segment elevation myocardial infarction (NSTEMI) (30%), followed by STEMI (14%), unstable angina (9%), and high-risk stress test (9%). Most target vessels were significantly diseased: 48% had moderate/severe tortuosity, 62% had moderate/severe calcification, and 13% were CTOs.
Of the 141 dissections, 104 (74%) had complete (33%) or partial (41%) coronary flow impairment. Intravascular imaging was used in 17% of the cases. In 43% of patients, there was no apparent clinical consequence of coronary dissection, and in 15% of patients the dissection required no treatment. Dissections that required treatment were most often treated with balloon angioplasty (32%) and stenting (73%), with a median number of 1(1-2) stents required for each dissection.
The procedural characteristics, consequences, and outcomes of the dissection patients are presented in Table 1. Technical and procedural success was 65% and 55%, respectively. In-hospital MACE occurred in 23% of patients: 13 (9%) had an acute MI, 3 (2%) underwent emergency CABG, and 10 (7%) died.
The most common cause of dissection was guidewire advancement (30%), followed by stenting (22%), balloon angioplasty (20%), and guide-catheter positioning (18%) (Figure 2A). Guidewire-induced dissections resulted in lower technical (36%) and procedural (31%) success, as well as higher acute MI rate (19%) compared with other causes of dissection. The procedural outcomes of coronary dissections stratified by the cause of dissection are presented in Table 2.
In 64 (45%) of the dissection cases, the guidewire was not maintained through the dissection segment. These cases had lower technical (47% vs. 79%; P<.001) and procedural (34% vs. 71%; P <.001) success rates, and also higher MACE (29.7% vs. 15.6%; P =.044) compared with cases where the guidewire position through the dissection segment was maintained (Figure 2B).
During a mean follow up of 1,612 days, 28 (20%) patients died, and the rate of target lesion revascularization was 11.3% (n=16) (Figure 3).
Discussion
The main findings from our study are that coronary artery dissections: (a) are infrequent (1.4%) and their incidence has not changed in recent years; (b) are caused most often by guidewire advancement; (c) are treated most often with stenting; (d) are associated with better outcomes if guidewire position was maintained across the dissection segment; and (e) are associated with MACE in approximately 1 of 4 patients.
The incidence of coronary dissection at our center was low, similar to prior studies.3,9-11 The most common cause of dissection was guidewire advancement (30%), followed by stenting (22%), and balloon angioplasty (20%) (Figure 2A).
Guide-catheter dissection is seen in <1% of PCI and is associated with deep engagement of large catheters into smaller, diseased arteries.12 In our study, guide-catheter positioning caused the dissection in 18% of the dissection cases (Figures 4 and 5). Amano et al3 examined the incidence and outcomes of guide catheter-induced iatrogenic coronary artery dissection in a study of 77,257 patients and reported an incidence of 0.14%, which is similar to our rate of dissections caused by the guide catheter (0.24%). Hiraide et al10 analyzed data from 17,225 consecutive patients undergoing PCI at 15 hospitals between 2008 and 2016 and reported the incidence, predictors, and in-hospital outcomes of catheter-induced coronary artery dissection. Catheter-induced dissection occurred in 185 patients (1.1%). Similar to our study, catheter-induced dissections was associated with high in-hospital mortality (6.5%) and in-hospital adverse cardiovascular events (14.1%). Patients who experienced catheter-induced dissections with decreased residual flow were at higher risk of postprocedural complications.10
While conservative management may be successful in patients with localized and minor dissections, stenting is usually required to prevent extension of the dissection.12 In our study, stenting was performed to treat the dissection in 73% of the cases. In a study of 56,968 patients undergoing coronary angiography by Ramasamy et al,11 catheter-induced dissections were managed with stenting in 82%.
The treatment of coronary dissection depends on lesion location and the severity of myocardial flow impairment.4 Some dissections are non-flow limiting and do not require treatment; others, obstruct flow, either partially or completely, and require treatment.13 Most patients in our study had partial to complete flow impairment. Maintaining wire position is critical when a dissection occurs.4 In 64 (45%) of the dissections cases in our study, the guidewire was not maintained through the dissection segment, resulting in a lower technical and procedural success rates, and also higher MACE compared with cases that the guidewire position was maintained through the dissection segment. In some cases when a wire was not advanced across the dissected coronary segment or wire position is lost, use of chronic total occlusion techniques, such as antegrade dissection and re-entry and the retrograde approach, can help the dissected segment and restore antegrade coronary flow.14-16
The incidence of MACE among dissection patients was 23%, highlighting the risk of adverse clinical consequences in patients who experience a coronary dissection during PCI. Every effort should, therefore, be undertaken to prevent dissections before they occur. Prevention methods include, avoiding injecting contrast if there is a dampened pressure waveform, maintaining coaxial guide catheter position, avoiding aggressive wiring strategies, appropriate balloon sizing and avoidance of very high-pressure balloons, and good lesion preparation before stenting.4,17 In addition to prevention, it is important to promptly treat dissections to avoid moderate/severe myocardial flow impairment.4,17
Limitations of our study include its retrospective observational design. Mild, non-flow limiting dissections may not have been reported, potentially leading to an underestimation of the true incidence of coronary dissections. There was no core laboratory assessment of the study angiograms or clinical event adjudication.
Conclusions
In conclusion, coronary dissections are infrequent, are most often caused by guidewire advancement and treated with stenting, and are associated with MACE in approximately 1 of 4 patients. Continued efforts are warranted for prevention and prompt treatment of this potentially life-threatening complication.
Acknowledgments. Study data were collected and managed using Research Electronic Data Capture (REDCap) electronic data capture tools hosted at the Minneapolis Heart Institute Foundation (MHIF), Minneapolis, Minnesota.5,6 REDCap is a secure, web-based application designed to support data capture for research studies, providing: (1) an intuitive interface for validated data entry; (2) audit trails for tracking data manipulation and export procedures; (3) automated export procedures for seamless data downloads to common statistical packages; and (4) procedures for importing data from external sources.
Affiliations and Disclosures
From the Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Allina Health Abbott Northwestern Hospital, Minneapolis, Minnesota.
Funding: The authors would like to thank the generous donors who have supported the 2022 MHIF internship program including Leonardus Loos and Shelley Holzemer for supporting a named intern for this study. The authors are grateful for the philanthropic support of our generous anonymous donors, and the philanthropic support of Drs Mary Ann and Donald A Sens, Mrs Diane and Dr Cline Hickok, Mrs Wilma and Mr Dale Johnson, Mrs Charlotte and Mr Jerry Golinvaux Family Fund, the Roehl Family Foundation and the Joseph Durda Foundation. The generous gifts of these donors to the Minneapolis Heart Institute Foundation's Science Center for Coronary Artery Disease (CCAD) helped support this research project.
Disclosures: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Allana: consulting for Boston Scientific Corporation and Abiomed. Dr Burke: consulting and speaker honoraria from Abbott Vascular and Boston Scientific. Dr Sandoval: previously served on the Advisory Boards for Roche Diagnostics and Abbott Diagnostics without personal compensation; and has also been a speaker without personal financial compensation for Abbott Diagnostics. Dr Brilakis: consulting/speaker honoraria from Abbott Vascular, American Heart Association (associate editor Circulation), Amgen, Asahi Intecc, Biotronik, Boston Scientific, Cardiovascular Innovations Foundation (Board of Directors), CSI, Elsevier, GE Healthcare, IMDS, Medicure, Medtronic, Siemens, and Teleflex; research support: Boston Scientific, GE Healthcare; owner, Hippocrates LLC; shareholder: MHI Ventures, Cleerly Health, Stallion Medical. All other authors: nothing to disclose.
Manuscript accepted January 20, 2023.
Address for correspondence: Emmanouil S. Brilakis, MD, PhD, Director of the Center for Complex Coronary Interventions, Minneapolis Heart Institute, Chairman of the Center for Coronary Artery Disease at the Minneapolis Heart Institute Foundation, 920 E 28th Street #300, Minneapolis, Minnesota 55407. Email: esbrilakis@gmail.com
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