Timir K. Paul, MD, PhD, FSCAI and Hany Ragy, MD, FSCAI

Introduction

Although an iatrogenic left main (LM) dissection is a rare complication with an incidence of 0.07–0.1%, it can rapidly lead to myocardial infarction (MI) and death; therefore, it demands emergent recognition and management.1–4 An iatrogenic LM dissection can be caused by either a diagnostic or guide catheter or with the use of interventional devices.3, 4 In this Tip of the Month, we focus on the preventable causes and management of an iatrogenic LM dissection.

Table 1: Causes and Prevention of an LM Dissection

Causes

Prevention

A. Iatrogenic

1. Noncoaxial catheter/guide position

1. Make every effort to engage the LM coaxially before a contrast injection.

2. Contrast injection while the pressure is dampened

2. Avoid a contrast injection if the pressure is damped.

3. Deep coronary engagement, especially in distal LM disease or ostial left anterior descending artery stenosis4, 5

3. Avoid deep catheter engagement and always check the pressure waveform before each injection.

4. Ostial/proximal stenosis6

4. Use a nonselective contrast injection to identify the stenosis. Avoid guides with side holes, as they mask pressure dampening.

5. Aggressive guide catheter manipulation, a

7F or 8F guide, and a stiffer guide (e.g., extra backup, Amplatz left)4, 6

5. Disengage the guide during any interventional device withdrawal to avoid inadvertent forward movement of the tip of the guide into the LM.

6. Use of a guide extension

6. Advance the guide extension over a balloon.

7. Aggressive guidewire manipulation, especially with a polymer-jacketed wire in diseased LMs

7. Avoid aggressive wiring; ensure the wire tip is always free in the LM; and exercise caution with polymer-jacketed guidewires.

8. Following balloon angioplasty, stenting, and atherectomy for calcified lesions

8. Use intravascular ultrasound (IVUS) pre-intervention to determine the lesion preparation technique and the optimal balloon and burr size.

9. Balloon rupture due to a calcified lesion (aortocoronary dissection)

9. Prepare the lesion using atherectomy devices in the calcified vessel.

B. Spontaneous LM coronary dissection (rare)

C. Aortic dissection extending into the coronary ostia

 

Diagnosis

  • Meticulous and cautious angiography in multiple orthogonal views
  • Use of Optical Coherence Tomography (OCT) or IVUS
  • More sensitivity with OCT than IVUS in detecting a dissection7

Treatment

  1. Secure the wire in the true lumen, which is the most important step in managing a dissection.
  2. Once the dissection is noted, avoid further contrast injections and, if needed, disengage the catheter for a nonselective injection. Instead, use IVUS to guide the intervention.
  3. Use rapid stent deployment, which is the mainstay of treatment.4, 8, 9
  4. In case stenting fails, call the surgeon immediately for an emergency coronary artery bypass graft (CABG).
  5. For an aorto-ostial lesion:
    1. In ostial LM stenosis, perform an intermittent guide disengagement, which may prevent ischemia. If the pressure dampens, prompt disengagement is necessary.
    2. Stent the coronary ostium, protruding 1–2 mm into the aorta to cover the ostium of the LM.
    3. Confirm the ostial LM stent placement in multiple angiographic views, particularly in a shallow left anterior oblique (LAO) cranial view.
    4. Use IVUS to guide the stent placement for complete ostial coverage.10
  6. In the presence of hemodynamic instability, first stent the LM dissection and then insert a left ventricular assist device and/or pacemaker.
  7. For a loss of wire position:
    1. Try to recross the wire with a soft wire in several orthogonal views.
    2. Try a parallel wiring technique, which may help to advance the wire in the true lumen while keeping a wire in the false lumen.
    3. Confirm the distal wire position in the true lumen, preferably by IVUS or alternatively by contrast injection via a microcatheter or over the wire balloon.
    4. Use IVUS to guide reentry into the true lumen and to confirm the distal true lumen wire position.11
    5. If unable to recross into the true lumen, patient will need emergent CABG. A mechanical support device may be needed to stabilize hemodynamics.

Summary

Preventive measures should be taken in cannulating LM to avoid a dissection. Keeping the guidewire in the true lumen is mandatory, and immediate diagnosis and rapid stenting are the keys to preventing propagation of the dissection and restoring blood flow.

References

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  2. Cheng CI, Wu CJ, Hsieh YK, et al. Percutaneous coronary intervention for iatrogenic left main coronary artery dissection. Int J Cardiol. 2008 May 23;126(2):177–82.
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  5. Dunning DW, Kahn JK, Hawkins ET, et al. Iatrogenic coronary artery dissections extending into and involving the aortic root. Catheter Cardiovasc Interv. 2000 Dec;51(4):387–93.
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  10. Abdou SM, Wu CJ. Treatment of aortocoronary dissection complicating anomalous origin right coronary artery and chronic total intervention with intravascular ultrasound guided stenting. Catheter Cardiovasc Interv. 2011 Nov 15;78(6):914–9.
  11. Ihdayhid AR, Brown AJ, McGaw D, et al. Threading the Eye of the Needle: A Challenging Case of Iatrogenic Spiral Coronary Artery Dissection. Heart Lung Circ. 2018 Jun;27(6):e73–e77.