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 Table of Contents  
Year : 2017  |  Volume : 14  |  Issue : 1  |  Page : 31-34

Percutaneous intervention for Optitorque tiger catheter-induced dissection of the right coronary artery and aortic root

Department of Cardiology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India

Date of Web Publication10-Mar-2017

Correspondence Address:
Ramachandra Barik
Department of Cardiology, Nizam's Institute of Medical Sciences, Hyderabad - 500 082, Telangana
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0189-7969.201905

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A 59-year-old female developed iatrogenic Type F spiral dissection of the right coronary artery (RCA) with retrograde extension as Type III aortic dissection (AD) during diagnostic coronary angiogram using 5 Fr Optitorque Tiger catheter. The spiral dissection of RCA was treated with angioplasty. AD was followed up with conservative management. The prompt identification of the starting point, the true lumen, and exit point of the dissection is the keys to the successful percutaneous revascularization. Visual eyeballing into multiple angiographic views is of immense help in the situation where optical coherence tomography and intravenous ultrasound are not available.

Keywords: Angioplasty, aortic dissection, coronary artery, iatrogenic spiral dissection, Optitorque tiger diagnostic catheter

How to cite this article:
Damera SR, Barik R, Sivaprasad A. Percutaneous intervention for Optitorque tiger catheter-induced dissection of the right coronary artery and aortic root. Nig J Cardiol 2017;14:31-4

How to cite this URL:
Damera SR, Barik R, Sivaprasad A. Percutaneous intervention for Optitorque tiger catheter-induced dissection of the right coronary artery and aortic root. Nig J Cardiol [serial online] 2017 [cited 2023 Mar 23];14:31-4. Available from: https://www.nigjcardiol.org/text.asp?2017/14/1/31/201905

  Introduction Top

The incidence of coronary artery dissection is <0.1% during routine diagnostic coronary angiogram.[1],[2] The frequency of iatrogenic right coronary artery (RCA) dissection is more common than the left coronary artery, especially doing angiogram using unusual catheter (Amplatzer), anomalous origin, and diseased ostium. Now, 5 Fr TIG Optitorque catheter (Terumo Corporation, NJ, USA) is used for routine diagnostic angiogram via transradial approach because less amount of Type I collagen around the ostium of coronary artery (RCA) with retrograde extension.[3] The diameter of the ostium of the left coronary artery was larger than that of the right. This is one of the very few diagnostic catheters which hook both the coronaries because of supportive primary and secondary curves. The true incidence of coronary artery dissection is not known using this catheter for routine angiogram. Tiger catheter which is known for its slender profile, soft body, and coaxial curves hooks most of RCA effortlessly and hooks deeply with relatively more clockwise rotation. The ostial or ostioproximal dissections may rarely extend retrogradely to the right coronary sinus and ascending aorta. Acute aortic dissection (AD) during cardiac catheterization has an estimated incidence of 0.02–0.04%.[4],[5] The incidence is higher during percutaneous coronary intervention (PCI) with an overall incidence of 0.03% than during diagnostic procedures (<0.01%).[6] It is more often seen while performing primary PCI than elective PCI. The extent of dissection ranges from A to F of National Heart, Lung, and Blood Institute (NHLBI) grade of dissection severity.[7] The associated AD may mandate surgical intervention, which carries a mortality risk of up to 25%.[8]

  Case Report Top

A 59-year-old female, nondiabetic, nonhypertensive, dyslipidemic, and body mass index of 24.9 kg/m 2 with Grade IIII stable angina pectoris Canadian Cardiovascular Society underwent coronary artery angiography (CAG) via right transradial approach using 5 Fr TIG Optitorque catheter (Terumo Corporation, NJ, USA). Coronary angiogram revealed mild disease of the left coronary artery and diffuse disease of RCA involving proximal and the middle part. Just after the completion of CAG, she suffered a spiral dissection (Type F, NHLBI) of RCA [Figure 1] and Videos 1 and 2] but there was no chest pain. This dissection extended retrogradely into the right coronary sinus and ascending aorta (Type III)[7] as shown in Video 3. Her hemodynamic was stable. Heparinization was reversed with protamine. Therefore, immediate PCI or coronary bypass graft was avoided and her condition was followed. Although emergency coronary bypass graft and aortic wall repair were planned, it was deferred because of the lack of consent. She continued to be asymptomatic. Angiogram after a month was performed to profile dissection [Figure 2] and Videos 4-8]. Computed tomographic (CT) angiography was not done. The RCA, right coronary sinus, and neighboring part of ascending aorta are shown in [Figure 2] and Videos 4-8. The angioplasty of dissection of RCA was done with the restoration of thrombolysis in myocardial infarction (TIMI) III flow. The starting point, lumen, and the exit points of dissection coronary artery were profiled with the support of multiple views. The procedure was done without optical coherence tomography (OCT) and intravenous ultrasound (IVUS) due to nonavailability. The right Judkin's guide catheter (6 Fr), PT ChoICE floppy guidewire (Boston Scientific, USA), and 1.25 mm Sprinter balloon (Medtronic Vascular, USA) were used to cross the entire length of dissection of length 50 mm were used for successful crossing of the dissection. Then, the lesion was successfully stented using two drug-eluting stents of size 28 mm × 2.5 mm and 23 mm × 2.75 mm in the distal to the proximal part in tandem with nominal pressure [Figure 2]d. The sealed and healed AD was left for further improvement [Figure 2]d and Videos 4-8].
Figure 1: Diagtnostic angiograms showed (a) selective and deep hooking of the right coronary by Optitorque 5 Fr diagnostic catheter; (b) inadvertent pull back without controlled counter clock torque caused antegrade (coronary) and retrograde (the right aortic sinus) dissection; (c) the progress retrograde dissection into ascending aorta; (d) the profile of spiral dissection and it's distal end in the right anterior oblique view after a month; (e) the profile of spiral dissection in left lateral view after a month; (f) nonselective right coronary angiogram after a month showed healed linear dissection line near sinotubular junction

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Figure 2: Angiographic views during angioplasty after a month showed (a) selective hooking of the right coronary artery using right Judkin's 6 Fr guide catheter showed spiral dissection the well-defined true lumen follows floor (green arrow) of the vessel; (b) the distal end of spiral dissection is followed in the right anterior oblique view showed with inner border (right-hand side of operator, marked by green arrow); (c) successful wiring of spiral dissection by the precision of unaided vision (no intravenous ultrasound or optical coherence tomography) and stenting; (d) the final result was TIMI III with adequate myocardial blush

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Ethical Committee approval was not sought though a detailed informed consent was taken for intervention.

  Discussion Top

Iatrogenic coronary artery dissection during diagnostic angiogram or PCI results from mechanical injury to the arterial wall during catheter or wire manipulation, passage or deployment of an interventional device, forceful injection of contrast medium, or balloon dilatation or stenting.[9] Patients with ostial coronary artery stenosis, hypertension, Marfan syndrome, congenitally unicuspid and bicuspid aortic valves, and cystic medial necrosis have been reported to be at higher risk of dissection.[10] A high index of suspicion is necessary during coronary angiography. The first documentation of coronary artery dissection or intimal tear was documented in 1981.[11] In 1991, a systematic classification of coronary artery dissection (A to F) as a complication of coronary angioplasty followed.[7] Iatrogenic coronary artery dissections extending into and involving the aortic root was described in 2000.[4]

Iatrogenic AD is a severe complication during cardiac catheterization. In many cases, the entry site is located in the coronary artery where a dissection occurs following trauma caused by the tip of the guiding catheter or balloon dilation. A forceful injection of contrast into the subintimal space may sometimes appear to play a major role in extending the dissection retrogradely to the aortic root with existing coronary ostial disease, deep hooking catheter, or malaligned catheter. The dissection in the coronary may extended to the Valsalva sinus and the ascending aorta.[12],[13] If a dissection is limited to the aortic sinus of Valsalva, it will resolve with conservative treatment only. However, when it extends over the aortic sinus of Valsalva, the treatment of an iatrogenic AD is still controversial. Dunning et al.[4] retrospectively reviewed nine coronary artery-ADs and reported that patients with limited aortic involvement were successfully managed with stenting of the entry point of the coronary dissection, whereas ADs extending more than 40 mm in length required surgical intervention. However, in some cases, excluding the entry point from the bloodstream by coronary stenting was sufficient to prevent the extension of the AD. In addition, this conservative management, defined as the “watchful waiting” strategy, showed a favorable evolution and constituted the definitive therapy.[14]

In our case, an extensive iatrogenic AD extending up to the entire ascending aorta without hemodynamic compromise had been effectively treated by coronary stent implantation. Stenting of the ostium of the RCA sealed the entry point of the dissection, preventing its further progression. The present case report suggests that if the patient is hemodynamically stable, sealing the coronary entry with a coronary stent, and excluding dissection progression with CT surveillance can be a reasonable strategy even in the case of an extensive dissection of the ascending aorta, reserving surgery for cases with documented progression of the dissection. It is empirical to use IVUS or OCT in this case for better identification of true lumen because routine angiographic views may not be able to identify the true lumen. Dilatation or stenting of false lumen further worsens the dissection inviting emergency coronary artery bypass grafting which is associated with higher mortality.[15],[16],[17] IVUS and OCT help in diagnosis, differential diagnosis, and true lumen identification for angioplasty. IVUS supports even the completion of angioplasty in such situation without using antegrade contrast injection or minimal number of angiographic views to prevent further dissection, but OCT always needs contrast injection to keep the lumen free of red blood cell for the proper imaging.[18],[19] However, OCT imaging offers a better spatial resolution than IVUS in this complication. Even today, the real practice in this situation is limited by nonavailability of IVUS and OCT everywhere and every time irrespective of geographic territory. We could successfully have completed angioplasty in the dissected RCA without the help of IVUS and OCT. The entire angioplastic reconstruction supported by the fair visual perception of spiral dissection in multiple angiographic views. This unusual illustration is an example of nonsurgical management of iatrogenic spiral dissection of RCA and contained retrograde Type III dissection. We could have further improved the quality of care in this using CT aortogram during follow-up just after dissection.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Barber-Chamoux N, Souteyrand G, Combaret N, Ouedraogo E, Lusson JR, Motreff P. Contribution of optical coherence tomography imaging in management of iatrogenic coronary dissection. Cardiovasc Revasc Med 2016;17:138-42.  Back to cited text no. 1
Eshtehardi P, Adorjan P, Togni M, Tevaearai H, Vogel R, Seiler C, et al. Iatrogenic left main coronary artery dissection: Incidence, classification, management, and long-term follow-up. Am Heart J 2010;159:1147-53.  Back to cited text no. 2
López-Mínguez JR, Climent V, Yen-Ho S, González-Fernández R, Nogales-Asensio JM, Sánchez-Quintana D. Structural features of the sinus of Valsalva and the proximal portion of the coronary arteries: Their relevance to retrograde aortocoronary dissection. Rev Esp Cardiol 2006;59:696-702.  Back to cited text no. 3
Dunning DW, Kahn JK, Hawkins ET, O'Neill WW. Iatrogenic coronary artery dissections extending into and involving the aortic root. Catheter Cardiovasc Interv 2000;51:387-93.  Back to cited text no. 4
Gómez-Moreno S, Sabaté M, Jiménez-Quevedo P, Vázquez P, Alfonso F, Angiolillo DJ, et al. Iatrogenic dissection of the ascending aorta following heart catheterisation: Incidence, management and outcome. EuroIntervention 2006;2:197-202.  Back to cited text no. 5
Wyss CA, Steffel J, Lüscher TF. Isolated acute iatrogenic aortic dissection during percutaneous coronary intervention without involvement of the coronary arteries. J Invasive Cardiol 2008;20:380-2.  Back to cited text no. 6
Huber MS, Mooney JF, Madison J, Mooney MR. Use of a morphologic classification to predict clinical outcome after dissection from coronary angioplasty. Am J Cardiol 1991;68:467-71.  Back to cited text no. 7
Trimarchi S, Nienaber CA, Rampoldi V, Myrmel T, Suzuki T, Mehta RH, et al. Contemporary results of surgery in acute type A aortic dissection: The International Registry of Acute Aortic Dissection experience. J Thorac Cardiovasc Surg 2005;129:112-22.  Back to cited text no. 8
Tomassini F, Gagnor A, Varbella F. Perforation of the sinus of Valsalva by guiding catheter during the percutaneous coronary intervention via the right transradial approach: A very unusual complication. Catheter Cardiovasc Interv 2011;78:888-91.  Back to cited text no. 9
Awadalla H, Sabet S, El Sebaie A, Rosales O, Smalling R. Catheter-induced left main dissection incidence, predisposition and therapeutic strategies experience from two sides of the hemisphere. J Invasive Cardiol 2005;17:233-6.  Back to cited text no. 10
Dorros G, Cowley MJ, Simpson J. National Heart, Lung, and Blood Institute Registry report of complications of percutaneous transluminal coronary angioplasty. Am J Cardiol 1981;47:396.  Back to cited text no. 11
Moles VP, Chappuis F, Simonet F, Urban P, De La Serna F, Pande AK, et al. Aortic dissection as complication of percutaneous transluminal coronary angioplasty. Cathet Cardiovasc Diagn 1992;26:8-11.  Back to cited text no. 12
Pérez-Castellano N, García-Fernández MA, García EJ, Delcán JL. Dissection of the aortic sinus of Valsalva complicating coronary catheterization: Cause, mechanism, evolution, and management. Cathet Cardiovasc Diagn 1998;43:273-9.  Back to cited text no. 13
Maiello L, La Marchesina U, Presbitero P, Faletra F. Iatrogenic aortic dissection during coronary intervention. Ital Heart J 2003;4:419-22.  Back to cited text no. 14
Koga S, Ikeda S, Nakata T, Maemura K. Spontaneous spiral dissection of left internal thoracic artery graft. Int Heart J 2015;56:360-2.  Back to cited text no. 15
Suarez-Mier MP, Merino JL. False lumen stent placement during iatrogenic coronary dissection. Cardiovasc Pathol 2013;22:176-7.  Back to cited text no. 16
Sakakura K, Wada H, Taniguchi Y, Mori M, Momomura S, Ako J. Intravascular ultrasound-guided coronary stenting without contrast medium for the treatment of catheter-induced aortocoronary dissection. Cardiovasc Interv Ther 2013;28:71-5.  Back to cited text no. 17
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;78:914-9.  Back to cited text no. 18
Abdou SM, Yip HK, Wu CJ. Transradial retrograde approach rescuing iatrogenic long spiral dissection during chronic total occlusion intervention. Catheter Cardiovasc Interv 2014;83:E159-64.  Back to cited text no. 19


  [Figure 1], [Figure 2]

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