2018 Volume 82 Issue 9 Pages 2383-2384
A 51-year-old man was admitted with acute chest and back pain. Computed tomography confirmed type A aortic dissection extending from the non- and right coronary sinuses of Valsalva to the iliac arteries. Both ostia of the right coronary artery (RCA) and left coronary artery (LCA) were not involved. Therefore, ascending aortic replacement and repair of the dissected sinuses of Valsalva using BioGlue with sandwich technique were performed. Postoperative transesophageal echocardiography (TEE) confirmed no dissection in the aortic root, but the patient developed hemodynamic shock 8 h after the surgery. TEE showed severely reduced left ventricular function, extension of the intimal flap into the LCA, and location of the false lumen in front of the RCA ostium. The stitching in the proximal aorta and/or inadequate coating of BioGlue on dissected membrane were considered as possible causes of recurrent dissection. Subsequent coronary angiography showed severe obstruction of the left main coronary artery (LMCA) and contrast staining in front of the RCA ostium with disturbed coronary flow (Figure A,F). Intravascular ultrasound (IVUS) indicated a semicircular medial dissection that compressed the true lumen in the LMCA (Figure B–E; Movie S1) and circumferential intimal disruption of the ostial RCA (Figure G–J; Movie S2) due to extended dissection. To restore coronary perfusion, a 4.0×15-mm drug-eluting stent was deployed in the LMCA, and a 4.0×28-mm stent was deployed to connect the original RCA and disrupted RCA ostium.
Coronary angiography and intravascular ultrasound (IVUS) before stent implantation. (A) Left coronary angiography showed severe obstruction of the left main coronary artery (LMCA). (B–E) IVUS showed the true lumen of the LMCA compressed by dissection. This also invaded the left anterior descending artery (LAD) and the left circumflex artery (LCX). (F) Right coronary angiography showed persistent contrast staining in the false lumen of the aortic root (*). IVUS showed (G) the exposed adventitia (dotted line) and remaining intimal flap (arrowheads) in the proximal right coronary artery (RCA), (H) the false lumen (*) in front of the original RCA ostium, (I) circumferential intimal disruption of the ostial RCA (arrows), and (J) the true lumen of the aorta.
IVUS was highly useful for clarifying the detailed mechanisms of coronary artery obstructions due to the involvement of aortic dissection.
The authors declare no conflict of interest.
Supplementary File 1
Movie S1. IVUS revealed the compressed true lumen of LMCA by the dissection, which also invaded into the LAD and LCX.
Supplementary File 2
Movie S2. IVUS demonstrated exposed adventitia and remaining intimal flap in the proximal RCA, false lumen in front of the original RCA ostium, circumferential intimal disruption of the ostial RCA, and true lumen of aorta.
Please find supplementary file(s);
http://dx.doi.org/10.1253/circj.CJ-18-0013
