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【論文摘要】Aortocoronary Dissection Resolved by Coronary Stenting and Guided by Intravascular Ultrasound
摘要
Introduction: Procedure-induced aortocoronary dissection was rarely reported. The incidence rate varies between 0% and 0.02% for diagnostic procedure and 0.03% and 0.15% for angioplasty procedures. Risk factors for aortocoronary dissection include older age, female gender, vessels with complex coronary anatomy (severe calcification, tortuousity of the vessel, extreme angulation, chronic total occlusion, and ostial lesion). Presentation: Percutaneous coronary intervention (PCI) was performed for diffusely critical stenosis of the proximal and mid right coronary artery (RCA) in a 90-year-old female with acute non-ST elevation myocardial infarction. Predilation with sequential sizes of balloon was performed initially. Aortocoronary dissection involving the right sinus of Valsalva and the ascending aorta occurred after stenting at mid RCA (figure A). Intravascular ultrasound (IVUS) showed the important characteristics of the dissection (figure B), enabling successful coronary stenting under IVUS guidance (figure C). After stenting at the entry site, no dissection flow was visible (figure D). Transesophageal echocardiography was performed 2 months later and demonstrated that neither aortic flap nor residual false lumen was found (figure E and F). Conclusion: Limited aortic involvement could be successfully managed with stenting of the entry point, whereas aortic dissection extending ＞ 40 mm up the aorta from the coronary ostium required surgical intervention. When it extends over the aortic sinus of Valsalva, advanced percutaneous or surgical intervention is often necessary. Iatrogenic ascenging aortic dissection can be encountered after coronary balloon angioplasty, especially in vessels with modest or heavy calcification. We successfully sealed the entry site of ascenging aortic dissection at ostial RCA with a bare metal stent without residual false lumen found after 2 months.