Iatrogenic catheter-induced ostial coronary artery dissections: Prevalence, management, and mortality from a cohort of 55,968 patients over 10 years

Abstract

Objective: We sought to describe the prevalence, management strategies and evaluate the prognosis of patients with iatrogenic catheter-induced ostial coronary artery dissection (ICOCAD).

Background: ICOCAD is a rare but potentially devastating complication of cardiac catheterisation. The clinical manifestations of ICOCAD vary from asymptomatic angiographic findings to abrupt vessel closure leading to myocardial infarction and death.

Methods: 55,968 patients who underwent coronary angiography over a 10-year period were screened for ICOCAD as defined by the National Heart, Lung, and Blood Institute. The management and all-cause mortality were retrieved from local and national databases.

Results: The overall prevalence of ICOCAD was 0.09% (51/55,968 patients). Guide catheters accounted for 75% (n = 37) of cases. Half of the ICOCAD cases involved the right coronary artery while the remaining were related to left main stem (23/51; 45%) and left internal mammary artery (2/51; 4%). Two-thirds of ICOCAD were high grade (type D, E, and F). The majority of cases were type F dissections (n = 18; 66%), of which two third occurred in females in their 60s. The majority of ICOCAD patients (42/51; 82%) were treated with percutaneous coronary intervention while the remaining underwent coronary artery bypass grafting (3/51; 6%) or managed conservatively (6/51; 12%). Three deaths occurred during the index admission while 48/51 patients (94.1%) were safely discharged without further mortality over a median follow-up of 3.6 years.

Conclusions: ICOCAD is a rare but life-threatening complication of coronary angiography. Timely recognition and prompt bailout PCI is a safe option for majority of patients with good clinical outcomes.

Keywords: angiography; complications; coronary; coronary aneurysm/dissection/perforation; diagnostic catheterization; percutaneous coronary intervention.

FIGURE 1

(a) The catheters involved in LMS dissection and (b) the catheters involved in RCA dissection. LMS, left main stem; RCA, right coronary artery [Color figure can be viewed at wileyonlinelibrary.com]

FIGURE 2

(b) Cases of ICOCAD according to the NHLBI classification, (b) type of dissection affecting each vessel and (c) the treatment delivered for each type of dissection. CABG, coronary artery bypass grafting; ICOCAD, iatrogenic catheter‐induced ostial coronary artery dissection; LIMA, left internal mammary artery; LMS, left main stem; NHLBI, National Heart, Lung and Blood Institute; PCI, percutaneous coronary artery intervention; RCA, right coronary artery [Color figure can be viewed at wileyonlinelibrary.com]

FIGURE 3

Seventy‐three‐year‐old male with previous CABG (LIMA‐LAD and SVG‐D1) who presented with NSTEMI. (a) Coronary angiography of the native vessels showing severe calcified and long length of occluded LAD stent. (b) Coronary angiography showing occluded distal LIMA/LAD after the insertion point. (c) Following a discussion at the complex coronary multidisciplinary meeting, the plan was to treat LIMA‐LAD followed by LMS‐LAD. Initial acquisition following IMA guide catheter engagement showed a type F dissection and loss of anterograde flow. (d) The dissection was promptly treated with 2 drug‐eluting stents. (e) Final angiographic image showing excellent TIMI III flow in the LIMA. (f) The LAD lesion was treated with one further stent and a drug‐eluting balloon, which resulted in good flow in the native LAD. The patient returned for a successful staged PCI‐LMS at a later date. CABG, coronary artery bypass grafting; LMS, left main stem; NSTEMI, non‐ST‐elevation myocardial infarction; PCI, percutaneous coronary artery intervention

FIGURE 4

Sixty‐two‐year‐old male presenting with an inferior NSTEMI. (a) First acquisition of the RCA with a JR4 guide catheter showed a severe spiral dissection (type F). (b) The RCA was carefully wired with a Sion blue wire. (c) The vessel was treated with two drug‐eluting stents and the final angiographic acquisition shows excellent TIMI III flow. NSTEMI, non‐ST‐elevation myocardial infarction; RCA, right coronary artery

FIGURE 5

Seventy‐nine‐year‐old female who presented with NSTEMI—case 3 in results. (a) Coronary angiography showing a severe stenosis of the proximal circumflex (culprit lesion). Significant tortuosity and calcification of the vessel is noted; (b). An AL2.0 guide catheter was chosen to provide backup support for intervention. First image acquisition following catheter engagement shows a severe LMS dissection with loss of antegrade flow. The patient was accepted for CABG but unfortunately, she died on her way to the operating theater on the same day. CABG, coronary artery bypass grafting; LMS, left main stem