Primer Perkütan Koroner Girişim Sırasında Katetere Bağlı Gelişen Aortokoroner Disseksiyon ve Tedavisi
Özet
Bu çalışmada, akut inferior miyokard infarktüsü tanısıyla acil servise başvuran 64 yaşındaki erkek hastada, primer perkütan koroner girişim (PKG) esnasında katetere bağlı gelişen aortokoroner disseksiyon vakası ve tedavisi sunulmaktadır. Sağ koroner arterdeki (RCA) total tıkalı lezyona yönelik gerçekleştirilen balon anjiyoplasti sonrasında, balonun geri çekilmesi esnasında kılavuz kateterin artere entübe olması nedeniyle RCA mid bölgeden asendan aorta uzanan bir disseksiyon meydana gelmiştir. İşlem sırasında hastanın koroner akımı tamamen kesilmiş ve iki kez ventriküler fibrilasyon gelişmiştir. Acil müdahale olarak, RCA ostiumundan başlayıp mid bölgeyi de kapsayacak şekilde birbiri ardına iki adet ilaç salınımlı stent başarıyla yerleştirilmiştir. Stentleme işleminin ardından koroner arter akımı normale dönmüş ve hem RCA hem de asendan aorttaki disseksiyon hattının tamamen kapandığı görülmüştür. Operasyondan 24 saat sonra çekilen toraks bilgisayarlı tomografisinde de disseksiyon izlenmemiştir. Hasta, yatışının dördüncü gününde herhangi bir komplikasyon gelişmeden taburcu edilmiştir. Bu vaka, nadir fakat hayatı tehdit eden iatrojenik disseksiyonlarda hızlı teşhis ve vaka bazlı doğru tedavi stratejisinin önemini ortaya koymaktadır.
This study presents a case of catheter-induced aortocoronary dissection and its successful treatment during a primary percutaneous coronary intervention (PCI) in a 64-year-old male patient who presented with an acute inferior myocardial infarction. Following balloon angioplasty for a totally occluded lesion in the mid-region of the right coronary artery (RCA), a coronary dissection extending from the mid-RCA to the ascending aorta occurred due to the guiding catheter intubating the artery while retrieving the balloon. During the procedure, the RCA blood flow ceased completely, and the patient experienced ventricular fibrillation twice. As an emergency treatment, two overlapping drug-eluting stents were successfully implanted, starting from the RCA ostium and covering the mid-region. Post-procedure imaging demonstrated complete restoration of coronary flow and closure of the dissection line in both the RCA and the ascending aorta. A thoracic computed tomography scan performed 24 hours after the operation showed no residual dissection. The patient was discharged without complications on the fourth day of hospitalization. This case highlights the vital importance of prompt diagnosis and customized management in dealing with rare but life-threatening iatrogenic dissections.
Referanslar
Brinker JA. Editorial comment: Geeez! Oh my God! Oops! #&*&††? Cathet Cardiovasc Diagn 1998;43:280–281.
Perez-Castellano N, GarcÌa-Fernandez MA, GarcÌa EJ, Delcan JL. Dissection of the aortic sinus of valsalva complicating coronary catheterization: Cause, mechanism, evolution, and management.Cathet Cardiovasc Diagn 1998;43:273–279.
Carter AJ, Brinker JA. Dissection of the ascending aorta associated with coronary angiography. Am J Cardiol 1994;73:922–923.
Awadalla H, Sabet S, Sebaie AE, et al. Catheter-induced left main dissection incidence, predisposition and therapeutic strategies: Experience from two sides of the hemisphere. J Invasive Cardiol 2005;17:233–236.
Goldstein JA, Casserly IP, Katsiyiannis WT, et al. Aortocoronary dissection complicating a percutaneous coronary intervention. J Invasive Cardiol 2003;15:89–92.
Dunning DW, Kahn JK, Hawkins ET, O'Neill WW. Iatrogenic coronary artery dissections extending into and involving the aortic root. Catheter Cardiovasc Interv 2000;51:387–393.
Nikolsky E, Boulos M, Amikam S. Spontaneous healing of a long, catheter-induced right coronary artery dissection. Int J Cardiovasc Intervent 2003;5:211.
Devlin G, Lazzam L, Schwartz L. Mortality related to diagnostic cardiac catherization. Int J Cardiovasc Imaging (formerly Cardiac Imaging) 1997;13:379–384.
Jain D, Kurowski V, Katus HA, Richardt G. Catheter-induced dissection of the left main coronary artery, the nemesis of an invasive cardiologist. Zeitschrift fur Kardiologie 2002;91:840.
Curtis MJ, Traboulsi M, Knudtson ML, Lester WM. Left main coronary artery dissection during cardiac catheterization. Can J Cardiol 1992;8:725–728.
Biel SI, Krone RJ. Left coronary artery dissection with an amplatz-shaped catheter. The role of vigorous inspiration during contrast injection. Chest 1984;86:640–641.
Boyle, Andrew J., et al. "Catheter-induced coronary artery dissection: risk factors, prevention and management." Journal of Invasive Cardiology 18.10 (2006): 500.
Al-Saif S, Liu M, Al-Mubarak N, et al. Percutaneous treatment of catheter-induced dissection of the left main coronary artery and adjacent aortic wall. Catheter Cardiovasc Interv 2000;49:86–89
Kim J-Y, Yoon J, Jung H-S, et al. Percutaneous coronary stenting in guide-induced aortocoronary dissection: Angiographic and CT findings. Int J Cardiovasc Imaging (formerly Cardiac Imaging) 2005;21:375–378.
Awadalla H, Salloum J, Smalling RW, Sdringola S. Catheter-induced dissection of the left main coronary artery with and without extension to the aortic root: A report of two cases and a review of the literature. J Intervent Cardiol 2004;17:253–257.
Gur M, Yilmaz R, Demirbag R, Kunt A. Large atherosclerotic plaque related severe right coronary artery dissection during coronary angiography. Int J Cardiovasc Imaging (formerly Cardiac Imaging) 2006;22:1–5.
Tam DY, Mazine A, Cheema AN, Yanagawa B. Conservative Management of Extensive Iatrogenic Aortic Dissection. Aorta. 2016;4(6): 229-231.
Chai H-T, Yang C-H, Wu C-J, et al. Utilization of a double-wire technique to treat long extended spiral dissection of the right coronary artery. Evaluation of incidence and mechanisms. Int Heart J 2005;46:35–44.
Dunning DW, Kahn JK, Hawkins ET, O'Neill WW. Iatrogenic coronary artery dissections extending into and involving the aortic root. Catheter Cardiovasc Interv. 2000;51(4):387-393.
Dorros G, Cowley MJ, Simpson J, et al. Percutaneous transluminal coronary angioplasty: report of complications from the National Heart, Lung, and Blood Institute PTCA Registry. Circulation. 1983;67 (4):723-730.
Eshtehardi P, Adorjan P, Togni M, et al. Iatrogenic left main coronary artery dissection: incidence, classification, management, and longterm follow-up. Am Heart J. 2010;159(6):1147-1153.
Alfonso F, Almeria C, Fernandez-Ortiz A, et al. Aortic dissection occurring during coronary angioplasty: Angiographic and transesophageal echocardiographic findings. Cathet Cardiovasc Diagn 1997;42:412–415.
