Iatrogenic Aortocoronary Dissection During Right Coronary Artery Procedures: A Systematic Review of the Published
Erick Sanchez-Jimenez1, Yaniv Levi1,2, Ariel Roguin1,2
1Cardiology Department, Hillel Yaffe Medical Center, Hadera, Israel.
Insights
Iatrogenic aortocoronary dissection (IACD) of the right coronary artery (RCA) is a rare complication. Stenting the RCA ostium is common, but conservative treatment can also be successful.
Area of Science:
- Cardiology
- Interventional Cardiology
- Vascular Surgery
Background:
- Iatrogenic aortocoronary dissection (IACD) is a serious complication during cardiac procedures.
- Risk factors and optimal management for IACD of the right coronary artery (RCA) remain unclear.
Purpose of the Study:
- To evaluate the characteristics, management strategies, and outcomes of patients experiencing IACD of the RCA.
Main Methods:
- A comprehensive literature search was conducted across medical databases.
- 142 cases of RCA IACD reported between 1973 and 2021 were analyzed.
Main Results:
- The majority of patients were male (57%), with a mean age of 63.0 years. High-grade dissection (Dunning class III) occurred in 54% of cases.
- Percutaneous coronary interventions (PCI) were the most common procedures (56%), with Judkins right catheters frequently used.
- Stenting of the RCA ostium was the most frequent intervention (62%), followed by conservative treatment (18%) and surgery (28%). Mortality was 6.5% for class III dissections.
Conclusions:
- While stenting the RCA ostium is a common intervention for IACD, a conservative approach may be feasible and successful in select cases.
- Individualized patient assessment is crucial for determining the optimal management strategy for RCA IACD.
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.
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