Asian Cardiovasc Thorac Ann 2002;10:58-60
© 2002 Asia Publishing EXchange Pte Ltd
Emergency Operation for Spontaneous Coronary Artery Dissection in Young Female
Yukitoshi Shirakawa, MD,
Goro Matsumiya, MD,
Shigeaki Ohtake, MD,
Yoshiki Sawa, MD,
Koji Kagisaki, MD,
Hikaru Matsuda, MD
|
Division of Cardiovascular Surgery Department of Surgery Osaka University Graduate School of Medicine Osaka, Japan
|
|
|
Yukitoshi Shirakawa, MD Tel: 81 6 6879 3154 Fax: 81 6 6879 3163 email: shira{at}surg1.med.osaka-u.ac.jp Division of Cardiovascular Surgery, Department of Surgery, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka 565-0871, Japan.
|
 |
ABSTRACT
|
|---|
Emergency coronary artery bypass grafting using a composite graft of the right internal thoracic artery and the radial artery was successfully performed for impending myocardial infarction secondary to spontaneous dissection of the right coronary artery in a 46-year-old woman. As spontaneous coronary artery dissection frequently presents as myocardial infarction or sudden death, timely diagnosis and intervention are required.
|
INTRODUCTION
|
|---|
Spontaneous coronary artery dissection is rarely identified antemortem. It has a different etiology from atherosclerotic coronary artery disease, as suggested by its risk factors and relatively young patient profile.1 Dissection frequently presents as myocardial infarction (MI) or sudden death, thus emergency intervention may be required.2
|
CASE REPORT
|
|---|
A 46-year-old woman with hypertension but no other risk factors for atherosclerotic coronary artery disease, experienced a sudden onset of severe anterior chest pain. She was in shock on arrival at the hospital. Her electrocardiogram showed complete atrioventricular block and negative T waves in leads III and aVF. Emergency cardiac catheterization and angiography showed a longitudinal filling defect extending from the right coronary artery orifice to just proximal to its bifurcation into the posterior descending and atrioventricular branches. The true lumen was compressed by a false lumen, resulting in 75% stenosis of the main right coronary artery (Figure 1
). Intravascular ultrasound showed that a flap divided the true and false lumens, and the dissected segment of the artery was enlarged to 7 x 6 mm (Figure 2). The patient's hemodynamic status was stabilized by insertion of an intraaortic balloon pump and recovery of atrioventricular conduction. However, at approximately 4 hours from the onset, the chest pain persisted, her plasma creatinine kinase-MB level was 6 U•L-1, and troponin T was positive. These conditions warranted urgent intervention. As the vessel was dilated up to 7 mm in diameter, and the lesion extended over a long segment, it was considered that angioplasty and intracoronary stenting were contraindicated, and coronary artery bypass grafting (CABG) should be performed. Via a median sternotomy, the right internal thoracic artery and left radial artery were harvested to construct a straight composite graft. Under cardiopulmonary bypass and cardioplegic arrest, the composite graft was anastomosed to the proximal normal portion of the posterior descending artery. The proximal end of the coronary artery was not ligated. The balloon pump was removed on the day of the operation, and the postoperative course was uneventful. A coronary angiogram 14 days postoperatively demon-strated that the bypass graft was patent and the native right coronary artery had antegrade flow. At follow-up after 7 months, the patient was doing well.
View larger version (121K):
[in this window]
[in a new window]
|
Figure 1. Coronary angiogram showing a longitudinal filling defect starting from the right coronary artery orifice and extending to a point just proximal to its bifurcation. The true lumen is compressed by a false lumen.
|
|
|
DISCUSSION
|
|---|
Spontaneous coronary artery dissection is a rare entity. A total of 155 cases have been described previously, of which 112 (72%) were in women, and 38% of these occurred during the 3rd trimester of pregnancy or the early postpartum period.3–5 Approximately half of all patients are under 40 years old.5 Multivessel involvement is rare; 75% of patients have single-vessel or left main trunk disease.5 The etiology is unclear, but it is suspected to differ in various types of patient.6 Changes in connective tissue caused by high estrogen levels include fragmentation of reticulum fibers, hypertrophy of smooth muscle cells, and alterations in the protein and acid mucopolysaccharide content of the media, which might explain the association with pregnancy.6 The theory most often proposed is that the dissection is caused by inflammatory changes, as some authors identified an infiltration of eosinophils in the adventitia of the vessel.6 However, other studies have not found this to be critical. It is possible that perivascular inflammatory changes might be the result rather than the cause of dissection. Systemic vasculitis including Kawasaki disease, collagen disease, and cystic medial necrosis in Marfan syndrome rarely causes coronary artery dissection. The vasa vasorum has been implicated in some reports as the possible site of initiation of coronary dissection. Because no intimal tear could be identified in some cases, it is speculated that rupture of the vasa vasorum with hemorrhage into the media could be the primary factor triggering dissection of a coronary artery.7
The treatment of spontaneous coronary artery dissection has not been well defined.1–3 Some authors have contended that asymptomatic patients with a nonocclusive dissection could be managed conservatively. In fact, 55% of the patients described in previous reports were treated medically.3–5 However, coronary artery dissection often presents as MI or sudden death, requiring urgent intervention.1 Some symptomatic patients with single-vessel disease have been treated by catheter intervention, and thrombolysis was used in 23 patients with good long-term prognoses.1–3 However, thrombolysis might cause bleeding or progression of dissection; thus percu-taneous transluminal angioplasty or stent implantation might be a more reasonable approach when the dissection is limited to a short segment. The indications for CABG are the same as in patients with acute coronary dissection secondary to atherosclerotic disease.
In this case, the patient continued to have chest pain with signs of impending MI; angioplasty and stenting were contraindicated because of the enlarged vessel diameter, thus CABG was performed. Although saphenous vein is the usual choice of conduit for emergency CABG, an arterial composite graft was selected in this case for the following reasons. First, the durability of saphenous vein graft is too limited for such a young patient. Second, she was hemodynamically stable with pump support, which allowed the experienced surgical team to spend a small amount of extra time constructing an arterial composite graft. Harrison and colleagues8 recommended identifying the origin of the dissection, ligating the vessel beyond this point, and anastomosing the graft distally. However, we did not perform this because it would risk making the distal circulation totally dependent on the graft, and extension of dissection after CABG has not been reported. If dissection exists in the distal portion, the layers of the vessel should be reapproximated during the anastomosis.
Spontaneous coronary artery dissection should be included in the differential diagnosis when a relatively young woman presents with acute MI. Early coronary angio-graphy should be undertaken to establish the diagnosis in such a patient. If dissection is visualized by angiography, revascularization should be considered without delay.
|
REFERENCES
|
|---|
-
Thayer JO, Healy RW, Maggs PR. Spontaneous coronary artery dissection. Ann Thorac Surg
1987;44:97–102.[Abstract]
-
DeMaio SJ, Kinsella SH, Silverman ME. Clinical course and long-term prognosis of spontaneous coronary artery dissection. Am J Cardiol
1989;64:471–4.[Medline]
-
Koen WJ, Koshal A, Boyd WD, Laramee L, Farrell E, Walley VM. Survival after spontaneous primary left main coronary artery dissection. J Cardiovasc Surg
1989;30: 786–9.[Medline]
-
Yoshida K, Mori S, Tomari S, Murakami F, Matsuura A, Hibi M, et al. Coronary artery bypass grafting for spontaneous coronary artery dissection: a case report and a review of the literature. Ann Thorac Cardiovasc Surg
2000;6:57–60.[Medline]
-
Siegel RJ, Koponen M. Spontaneous coronary artery dissection causing sudden death: mechanical arterial failure or primary vasculitis. Arch Pathol Lab Med
1994;118:196–8.[Medline]
-
Jorgensen MB, Aharonian V, Mansukhani P, Mahrer PR. Spontaneous coronary dissection: a cluster of cases with this rare finding. Am Heart J
1994;127:1382–7.[Medline]
-
Versaci F, Tomai F, Gaspardone A, Proietti F, Chiariello L, Gioffre PA. Stent implantation for spontaneous coronary dissection. Cardiologia
1997;42:971–4.[Medline]
-
Harrison LY Jr, Gregg DL, Itscoitz SB, Redwood DR, Michaelis LL. Delayed coronary artery dissection after angiography. A case description with successful operative treatment. J Thorac Cardiovasc Surg
1975;69:880–3.[Abstract]
This article has been cited by other articles:
|
|
|
|
 
R. Cini, F. Iezzi, P. Sordini, and V. Pasceri
Spontaneous left main coronary artery dissection
Interactive CardioVascular and Thoracic Surgery,
October 1, 2008;
7(5):
943 - 944.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. Ooi, M. Lavrsen, J. Monro, and S. M. Langley
Successful emergency surgery on triple-vessel spontaneous coronary artery dissection
Eur. J. Cardiothorac. Surg.,
August 1, 2004;
26(2):
447 - 449.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
D. Carmi, G. Touati, M. Barry, and E. Dadez
Spontaneous coronary artery dissection: value of beating heart myocardial revascularization
Interactive CardioVascular and Thoracic Surgery,
December 1, 2003;
2(4):
694 - 696.
[Abstract]
[Full Text]
[PDF]
|
|
|
TOP
ABSTRACT
INTRODUCTION
