Left Main Coronary Artery Dissection

Complicating Diagnostic Coronary

AngiographyLayth A. MimishMBChB, FRCPC, FACC

Medical DirectorThe Cardiovascular Consultant Clinic

Jeddah, KSA

I have no conflict of interest

pertaining to this presentation

Left Main Coronary Dissection• Definition and Classification• Incidence• Etiology• Management

Conservative

CABGS

Stenting

NHLBI Classification

Left Main Coronary Dissection•Spontaneous•Extension from Aortic Dissection•Complication of Diagnostic Coronary Angiography or Coronary Interventional procedure

Iatrogenic Left Main Coronary Dissection

• Calcification of Lt. Main Stem• Anatomical distortion in aortic root or origin of

Lt main that makes selective intubation difficult• The angle formed by the tip of the catheter and

the intima of the vessel• The depth with which the artery is cannulated• Forceful injection with dampened pressure• Femoral Vs radial approach• Diagnostic Vs PCI

Left Main Coronary Dissection

• Sone’s initial series 4200 diagnostic procedures, 1 reported dissection

• Massachusetts General Hospital 1970-1975 2981 Pts, Lt. main dissection in 1

• Dennis, W., William O’Neil, Cath C V Intervention 2000, data review 43,143 diagnostic procedures and PCI (0.02%)

• Carter AJC 1994 3cases, incidence 0.02 for diagnostic angiography, and 0.07% for PCI

• Under-reported, with severity varying from type A to severe aortic root dissection

Conservative Treatment

CABG Vs Medical Therapy

ACC / AHA Guidelines

Clinical Outcomes with CABG

in Lt. Main Disease•18 Centers• Jan 2001-June 2003•5,494 Consecutive CABG with no exclusion

•1,394 Lt main (24.1%)•Operative mortality 4.1% (All other CABG 2.3%)

•CVA 1.3%

Katz, Mack, Simon

OPCAB in LMCA Disease

Off PumpOn Pump

n2731,163

Predicted Mortality

4.1%3.6%

Observed Mortality

2.6%4.5%

Risk Adjusted Mortality

1.9%3.8%

Dewey,et al, Ann Thorac Surg 2001

Motality for CABG in Lt Main

NYS Database 1997-2000

Stent Vs Conventional Rxfor Abrupt Closure or

Symptomatic Dissection

French Lt Main RegistryMay 2001-June 2002 (11

French Centers)

French Lt Main Registry

1 Yr Outcome

French Lt Main Registry

1 Month &1 Yr Outcome

French Lt Main Registry

1 Month &1 Yr Outcome

French Lt Main Registry

1 Month &1 Yr Outcome

IVUS Optimization for Stent Deployment

DES Vs BMS in Milan6 Month Clinical & Angiographic F/Up

DES in Lt Main DiseaseRESEARCH & T-SEARCH

Registry

• April 16, 2002-Dec 31, 2003• > 50% Lt min• Consensus agreement with CV surgeon

with patient and referring MD• 95 Consecutive Pts, with 1 DES (SES 52,

PES 43)• Comparison group 86 Consecutive pts

who got BMS for Lt main immediately before DES availability

• Median F/UP 503 days (331-873)

DES in Lt Main DiseaseRESEARCH & T-SEARCH

Registry

LMCA Intervention in AMC

In Hospital Outcome

Overall Restenosis rate 7.9%

6 Months Clinical Outcome

MACE Free Survival at 1 Year

Coclusion

•Rapid & thorough assessment

•CV Surgeon involved

•Haemodynamic support

•DES Vs emergency CABGS

•IVUS