PCI complications: dissection

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Factors Associated with Complications
Vessel Perforation
Dissection
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [2], Vanessa Cherniauskas, M.D. [3]

Overview

A coronary artery dissection refers to a split or a tear in the wall of the artery which compresses or compromises the lumen of the artery reducing blood flow. Coronary artery dissection occurs rarely in the absence of percutaneous coronary intervention (PCI). The risk of reduced anterograde flow and lumen narrowing is a relatively (< 3%) uncommon complication of PCI. Significant residual dissections are present in approximately 1.7 % of patients undergoing PCI.[1] Intracoronary stent placement is used to stabilize the dissection.

Classification

The National Heart, Lung and Blood Institute (NHLBI) coronary dissection criteria assign according the severity of coronary dissection following PCI, with the prognostic implications of the coronary dissection depending on extension into the media and adventitia, its axial length, presence of contrast staining, and effect on anterograde coronary perfusion.

Difficulties can be present when assessing the angiographic residual lumen in the presence of coronary dissection due to the frame-to-frame lumen diameter changes using two-dimensional imaging; intravascular ultrasound (IVUS) may be more accurate strategy to provide the true circumference lumen dimensions.

In the NHLBI scheme, dissection is defined as an intraluminal filling defect or flap associated with a hazy, ground-glass appearance. This category is sub-classified using the NHLBI (National Heart Lung and Blood Institute) system for grading dissection types:[2]

Type A

Type B

  • Type B dissections are parallel tracts or double lumen separated by a radiolucent area during contrast injection, with minimal or no persistence after dye clearance.

Type C

  • Type C dissections appear angiographically as contrast outside the coronary lumen ("extraluminal cap") with persistence of contrast in the area after clearance of dye from the coronary lumen.

Type D

  • Type D dissections represent spiral ("barber shop pole") luminal filling defects, frequently with extensive contrast staining of the vessel.

Shown below are an animated image and a static image depicting coronary artery dissection type D. Outlined in yellow is the spiral luminal filling defect that characterizes type D coronary artery dissection.

Spiral dissection.gif Dissection spiral-static.gif

Type E

  • Type E dissections appear as new, persistent filling defects.
  • As proposed by the Coronary Angioplasty Registry, type E dissection may be caused by thrombus.

Type F

  • Type F dissections represent those that lead to total occlusion of the coronary artery, without distal anterograde flow.
  • As proposed by the Coronary Angioplasty Registry, type F dissection may be caused by thrombus.
Other Associated Definitions/Terms

Pathophysiology

The two primary mechanisms accounting for disruption of the coronary vessel wall include barotrauma and guiding catheter dissections. Most coronary dissections occur as a result of percutaneous coronary intervention, but they may also occur either as an extension of an aortic dissection into the right coronary artery, or in the setting of coronary bypass grafting. Spontaneous coronary artery dissection is itself rare.

Histopathological Findings

Images courtesy of Professor Peter Anderson DVM PhD and published with permission © PEIR, University of Alabama at Birmingham, Department of Pathology

Treatment

Coronary stent placement, surgery and anticoagulation would appear to be reasonable treatment modalities.[3] Given the rare nature of the disease, randomized trial data is obviously lacking. Most intra-procedural dissections can be treated promptly with stenting.

Angiography

Click here to view angiography examples of the different types of coronary artery dissection.

References

  1. Laskey WK, Williams DO, Vlachos HA; et al. (2001). "Changes in the practice of percutaneous coronary intervention: a comparison of enrollment waves in the National Heart, Lung, and Blood Institute (NHLBI) Dynamic Registry". Am. J. Cardiol. 87 (8): 964–9; A3–4. PMID 11305987.  Unknown parameter |month= ignored (help)
  2. Huber, MS.; Mooney, JF.; Madison, J.; Mooney, MR. (1991). "Use of a morphologic classification to predict clinical outcome after dissection from coronary angioplasty.". Am J Cardiol. 68 (5): 467–71. PMID 1872273.  Unknown parameter |month= ignored (help)
  3. Narasimhan, S (2004). "Spontaneous coronary artery dissection (SCAD)" (PDF). IJTCVS. 20 (4): 189–91. doi:10.1007/s12055-004-0084-x. 

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