A case of coronary artery dissection after aortic replacement in acute type a aortic dissection

Abstract

A 59-year-old woman was transferred to our institution with a diagnosis of acute type A aortic dissection. During aortic replacement surgery, the dissection had not extended to the orifice of the left coronary artery. However, ST segment elevation was observed on an electrocardiogram monitor immediately postoperatively. An emergent coronary angiogram showed almost complete collapse of the lumen of the left coronary artery due to pulsatile compression of the false lumen, which was caused by extension of the aortic dissection. Percutaneous coronary intervention (PCI) was performed with placement of stents in the left anterior descending artery (LAD) and left circumflex artery. Coronary angiography and intravascular ultrasound performed 45-days after PCI showed significant instent restenosis (ISR) at the proximal portion of the LAD and residual coronary artery dissection of the diagonal branch. Repeat balloon angioplasty was performed at the site of the ISR. A follow-up coronary angiogram 8-months after the PCI showed no evidence of ISR.

Keywords: Aortic diseases; Cordiovascalar surgical procedures; Myocardial infarction; Percutaneous transluminal coronary angioplasty.

Fig. 1

Chest X-ray showing mediastinal widening.

Fig. 2

Initial electrocardiogram showed normal sinus rhythm with a premature atrial complex. There were no significant ST-T changes.

Fig. 3

Emergent computed tomogram of the chest showing an acute Stanford type A aortic dissection (A). The left coronary artery had good patency and no dissection (B).

Fig. 4

Electrocardiography demonstrated ST segment elevation in leads II, III, and aVF, and in the precordial leads immediately postoperatively.

Fig. 5

Postoperative emergent coronary angiogram showing almost complete collapse of the lumen of the left anterior descending artery (A). After forceful contrast injection into the left anterior descending artery, the lumen of the collapsed left anterior descending artery which had been reopened, subsequently recollapsed (arrows). The dissection encircled the affected coronary ostium and the observed malperfusion was produced by direct coronary blood flow obstruction. Similar findings were obtained in the left circumflex artery (arrows) (B).

Fig. 6

Follow-up coronary angiogram performed 45-days after percutaneous coronary intervention showing significant in-stent restenosis at the proximal portion of the left anterior descending artery in the anteroposterior caudal (arrow) (A) and in the left anterior oblique caudal views (arrow) (B).

Fig. 7

The intravascular ultrasound study showed significant in-stent restenosis in the proximal portion of the left anterior descending artery and remaining coronary artery dissection in the diagonal branch of the left anterior descending artery (*). There was no significant instent restenosis or remaining dissection of the left circumflex artery.

Fig. 8

Follow-up coronary angiogram performed 8 months after percutaneous coronary intervention showing no significant in-stent restenosis.