Eur J Cardiothorac Surg 2002;21:363-364
© 2002 Elsevier Science NL
Bypassing a dilemma: intraoperative coronary angiography in acute aortic dissection
Eugenio Neri*,
Massimo Massetti,
Carlo Sassi
Istituto di Chirurgia Cardiovascolare Universita’ agli Studi di Siena, Unita’ Operativa di Chirurgia dell’ Aorta Toracica, Policlinico le Scotte, Viale M.Bracci, 53100 Siena, Italy
Received 21 September 2001;
received in revised form 25 October 2001;
accepted 15 November 2001.
* Corresponding author. Tel.: +39-0577-585-733; fax: +39-0577-281-937
e-mail: euxneri{at}tin.it
e-mail: nerie{at}unisi.it
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Abstract
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Untreated coronary artery disease may complicate the clinical course of patients with Stanford type A acute aortic dissection. In these patients the role of coronary angiography for the assessment of coronary circulation is controversial and it is considered by some time consuming thus increasing the risk of rupture. We describe a case of acute type A aortic dissection that illustrates our approach to this problem.
Key Words: Aneurysm, dissecting/diagnosis/surgery • Coronary disease/prevention and control/radiography • Coronary angiography
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Introduction
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In recent years progress in non-invasive diagnostic techniques, in particular transesophageal echocardiography, has made angiography unnecessary to establish or confirm the diagnosis of acute dissection. Angiography still represents the gold standard for evaluating the coronary anatomy and to distinguish acute coronary artery disease, due to ostial dissection from chronic coronary artery disease. Nevertheless the role of coronary angiography before emergency repair of acute aortic dissection is controversial. Because of the high incidence of coronary disease in older patients with dissection, some studies have advocated routine coronary angiography [1], whereas others have found increased mortality when angiography is performed. A recent paper by Penn et al. [2] indicates that determination of coronary anatomy has not had an impact on survival. Rizzo et al. [3] found angiography to be associated with increased mortality due to aortic rupture during the delay before surgical intervention.
We describe a case of acute type A aortic dissection that illustrates how this controversy can be overcome.
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1. Case presentation
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A 68-year-old hypertensive man was admitted to our hospital in October 2000 with severe chest pain of abrupt onset. An enlarged mediastinal silhouette on chest film and the demonstration, on transthoracic echocardiography, of an intimal flap in the ascending aorta, together with the presence of a significant pericardial effusion and moderate to severe aortic regurgitation, were highly suggestive of an aortic dissection. The patient had a history of exertional angina treated with beta-blockers. A 12-lead EKG performed on admission demonstrated antero-lateral ischemia. The hemodynamic condition was unstable because of cardiac tamponade (CVP=37 mmHg, MAP=85/32) and so the patient was therefore transferred to the operating room without delay.
The chest was opened through a median sternotomy and the pericardium entered. There was not a frank aortic rupture and the hemodynamic condition recovered after evacuation of 900cc of bloody exudate. Epicardial palpation of the coronary arteries found diffuse calcifications of both right and left systems, whereas intraoperative transesophageal echocardiography showed septal and anterolateral hypokinesia. We decided to perform intraoperative coronary angiography, using a portable imaging fluoroscopic system (Digital Mobile C-Arm, Series 9600; OEC Medical Systems, Salt Lake City, UT). In the meanwhile cardiopulmonary bypass was instituted using the left axillary artery for arterial inflow and a double stage cannula for venous return. With the beating heart aortography and coronary angiography were performed using a standard technique through a femoral arterial access and a 6F-guiding catheter. Coronary angiography showed an isolated critical stenosis in the proximal LAD artery (Fig. 1)
. We decided to treat the lesion with a saphenous CABG graft for the LAD that was accomplished during the cooling period before hypothermic circulatory arrest (20°C). The intimal tear was located 2 cm above the sino-tubular junction. The ascending aorta and the proximal portion of the transverse arch were replaced with an open technique and the aortic valve was resuspended during rewarming. Postoperative course was uneventful and the patient was discharged from the intensive care unit after 24 h and from the hospital 8 days later.
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Fig. 1. Intraoperative coronary angiogram (LAO 45°) demonstrating severe narrowing of the LAD due to an eccentric plaque.
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2. Discussion
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This case indicates that angiography can be performed most safely in the operating room after stabilization of the hemodynamic condition. Intra-operative angiography overcomes the dilemma of angiography in aortic dissection, providing valuable information about coronary circulation and anatomy without time delay in setting up and performing the test in these critically ill patients. Furthermore it has the advantage of delineating the major arterial branches, their involvement in the dissection process as well as the blood supply to vital organs.
Intraoperative coronary angiography has already been successfully performed to confirm graft patency immediately after minimally invasive coronary bypass operations [4,5] thanks also to the recent availability of portable digital X-ray imaging systems, which are capable of a good range of angiographic angles and high speed dynamic recording and playback.
In the present case we preferred a standard technique of catheterisations and we did not experience difficulties in placing the catheter into the aortic true lumen. Intraoperative angiography allowed an excellent visualization of the aorta and of the coronary arteries; however, in aortic dissection the technique is not exempt from risks, therefore it should be reserved to selected cases with clinical suspicion of coronary artery disease. In the event of a difficult ‘navigation’ inside the aorta, or when sophisticated fluoroscopy equipments are not available, a coronary angiogram can be obtained transecting the aorta and injecting the contrast medium directly into the coronary ostia, similarly to bench ex vivo coronary angiography for donor hearts [6].
In this patient CABG was preferred to intraoperative PTCA because of the eccentricity of the lesion, the origin of a septal branch in the proximity of the stenosis as well as the calcification of the plaque, however PTCA may represent an effective approach for future cases. Furthermore intra-operative angiography may represent a valid method for the diagnosis and treatment of malperfusion of end organs associated with aortic dissection [7].
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References
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Creswell L.L., Kouchoukos N.T., Cox J.L., Rosenbloom M. Coronary artery disease in patients with type A aortic dissection. Ann Thorac Surg 1995;59:585-590.[Abstract/Free Full Text]
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Penn M.S., Smedira N., Lytle B., Brener S.J. Does coronary angiography before emergency aortic surgery affect in-hospital mortality?. J Am Coll Cardiol 2000;35:889-894.[Abstract/Free Full Text]
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Rizzo R.J., Aranki S.F., Aklog L., Couper G.S., Adams D.H., Collins J.J., Jr, Kinchla N.M., Allred E.N., Cohn L.H. Rapid non-invasive diagnosis and surgical repair of acute ascending aortic dissection: improved survival with less angiography. J Thorac Cardiovasc Surg 1994;108:567-575.[Abstract/Free Full Text]
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Mack M.J., Magovern J.A., Acuff T.A., Landreneau R.J., Tennison D.M., Tinnerman E.J., Osborne J.A. Results of graft patency by immediate angiography in minimally invasive coronary artery surgery. Ann Thorac Surg 1999;68:383-389.[Abstract/Free Full Text]
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Goldstein J.A., Safian R.D., Aliabadi D., O'Neill W.W., Shannon F.L., Bassett J., Sakwa M. Intraoperative angiography to assess graft patency after minimally invasive coronary bypass. Ann Thorac Surg 1998;66:1978-1982.[Abstract/Free Full Text]
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Lee C.C., Aruny J.E., Laurence R.G., Appleyard R.F., Couper G.S., Cohn L.H. Bench coronary angiography: a potentially useful method to assess coronary artery disease in the older donor heart without catheterization laboratory angiography. J Heart Lung Transplant 1992;11:693-697.[Medline]
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Slonim S.M., Miller D.C., Mitchell R.S., Semba C.P., Razavi M.K., Dake M.D. Percutaneous balloon fenestration and stenting for life-threatening ischemic complications in patients with acute aortic dissection. J Thorac Cardiovasc Surg 1999;117:1118-1127.[Abstract/Free Full Text]
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Abstract
Introduction
