Iatrogenic Aortocoronary Dissection During Right Coronary Artery Procedures: A Systematic Review of the Published Literature

Abstract

Iatrogenic aortocoronary dissection (IACD) occurs mainly during procedures involving the right coronary artery (RCA) and can result in disabilities, the need for urgent complex surgery, and even death. The risk factors for IACD are ill characterized, and the best management strategy is questionable; thus, there is a need to evaluate the characteristics, treatment options, and outcomes of patients with IACD of the RCA. We searched medical databases for publications on IACD of the RCA to present the characteristics of the procedures, management, and outcomes. We report 142 cases of IACD of the RCA, reported between 1973 and 2021. The mean age of the patients was 63.0 years, 81 (57%) were men, 75 (52.8%) presented with stable angina, and 29 (20.4%) had chronic total occlusion of the RCA. The most used catheter shapes were Judkins right (42%) and Amplatz left (25%), and most (56%) catheters were used during percutaneous coronary interventions. Guiding catheters were used in 38% (19/50) of diagnostic procedures when IACD occurred. A catheter size of ≤5F was used in only 3 cases. The catheter size was 6F in 22% of the cases, >6F in 23%, and not reported in 52%. A high-grade dissection (Dunning class III) occurred in 54% (77/142) of the cases. Stenting of the RCA ostium was performed in 88 (62%) of the cases, conservative treatment in 25 (18%), and surgery in 40 (28%) (aortic root repair [5%], coronary artery bypass grafting and aortic root repair [11%], and coronary artery bypass grafting alone [10%]). The mortality rate was 6.5% (5/77) among patients with class III dissection. Each patient should be considered independently. The most frequent intervention was to seal the dissection with a stent in the ostial RCA. However, in select cases published in the literature, a conservative approach was a feasible and successful option.

Keywords: aortocoronary dissection; catheter-induced aortic dissection; catheter-induced aortocoronary dissection; iatrogenic coronary dissection; stent.

Graphical abstract

Central Illustration

Aortocoronary dissection: mechanisms, types and management. AVR, aortic valve replacement; CABG, coronary artery bypass grafting.

Figure 1

Right coronary artery (RCA) iatrogenic aortocoronary dissection. A 66 year-old man with ST-elevation myocardial infarction. (A) RCA angiography using the Amplatz left 0.75 guiding catheter. The arrow points to the tip of the catheter pulling on the inferior wall of the proximal arterial segment and deep cannulation, best seen in (B), just after contrast washout. (C) The next contrast injection with a proximal D-type RCA dissection with retrograde extension to the right coronary sinus, in which the contrast is contained. (D) Placement of a drug-eluting stent protruding from the coronary ostium with the intention of sealing the flap and preventing extension of the dissection into the ascending aorta.