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(Chest. 2001;119:493-501.)
© 2001 American College of Chest Physicians

Unusual Complication of Retrograde Dissection to the Coronary Sinus of Valsalva During Percutaneous Revascularization*

A Single-Center Experience and Literature Review

Hon-Kan Yip, MD; Chiung-Jen Wu, MD; Kuo-Ho Yeh, MD; Chi-Ling Hang, MD; Chi-Yuan Fang, MD; Kelvin Yuan-Kai Hsieh, MD and Morgan Fu, MD

* From the Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Kaohsiung Medical Center, Kaohsiung, Taiwan, Republic of China.

Correspondence to: Hon-Kan Yip, MD, Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, 123 Taipei Road, Niao Sung Hsiang, Kaohsiung Hsien, Taiwan, Republic of China


   Abstract
TOP
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 References
 
Background: While coronary dissection, which is one of the most frequently occurring complications during interventional procedures, has various forms, extensive coronary dissection retrograde to the coronary sinus of Valsalva (CSV) is very rarely observed.

Methods and results: Within the last 5 years, we retrospectively reviewed our experience with 4,700 consecutive patients who underwent angioplasty procedures, 7 of whom (0.15%) developed extensive coronary dissection retrograde to the CSV. Six of the seven patients developed retrograde dissection of the right CSV during angioplasty to the right coronary artery. One of the seven patents developed retrograde dissection of the left CSV during angioplasty to the left anterior descending artery. Retrograde dissection, which extended to the ascending aorta in two patients, was observed by transthoracic echocardiography and surgical findings, respectively. Five patients were successfully treated by coronary stenting. However, this complication caused four patients to have acute myocardial infarctions, resulting in emergency surgery for one patient and in-hospital death for another.

Conclusions: Our experience increased our understanding of this very rare complication. However, this complication may be life threatening, and patients in this clinical setting may have a potential risk for acute myocardial infarction, emergency surgery, or even sudden cardiac death. Therefore, it is important to learn how to promptly diagnose and manage this complication.

Key Words: aortic dissection • coronary angioplasty • coronary stenting • sinus of Valsalva dissection


   Introduction
TOP
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 References
 
During the last part of the 1970s, Gruntzig, a pioneer interventional cardiologist, revolutionized the management of coronary artery disease with the development of percutaneous transluminal coronary angioplasty (PTCA).1 This was a turning point in the treatment of myocardial ischemia by less invasive methods. Today, PTCA provides the option of nonsurgical revascularization for up to one half of patients who undergo diagnostic catheterization for angina pectoris or acute coronary syndrome. Because of the continuous development of new devices, 23 4 technical refinements,4 5 6 increasing operator experience, and new developments in preprocedural, intraprocedural, and postprocedural regimens,7 8 9 interventional cardiologists are using these techniques in increasingly difficult cases. However, procedure-related complications such as coronary dissection, coronary or myocardial perforation, acute coronary occlusion, or serious dysrhythmia, which may lead to emergency surgery, nonfatal myocardial infarction, or even a fatal outcome, may vary substantially, depending on the clinical, angiographic, and procedural characteristics.10 11 12

We reviewed our experience with seven patients undergoing PTCA to either the left anterior descending artery (LAD) or the right coronary artery (RCA) who had retrograde dissection of the coronary sinus of Valsalva (CSV). The aim of this study was to delineate the incidence rate, the potential risk, the characteristics, and the mechanism of formation of retrograde dissection of the CSV and to clarify the optimal management of patients with this difficult complication.


   Materials and Methods
TOP
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 References
 
Patient Population
Between May 1995 and September 1999, 13,000 patients underwent cardiac catheterization at Chang Gung Memorial Hospital, Kaoshiung Medical Center. We identified that no patient developed retrograde dissection to the CSV among 8,300 diagnostic catheterization cases. However, we observed that 7 of 4,700 patients who underwent coronary angioplasty did develop retrograde dissection of the CSV. Of these patients, six had retrograde dissection of the right CSV during PTCA to the RCA and one had retrograde dissection of the left CSV during PTCA to the LAD. Therefore, the incidence rate of this complication was 0% for diagnostic catheterization and 0.15% for angioplasty procedures.

Preangioplasty and Postangioplasty Strategies and Angioplasty Procedures
The indication for catheterization was unstable angina, or post-myocardial infarction angina in these patients. A percutaneous transfemoral approach was used for the first six patients, and a left transradial approach was used for the last patient. The guiding catheters and guidewires that were chosen for PTCA are summarized in Table 1 . After the guidewire was determined to have crossed the lesion and advanced into the true lumen, a suitably sized balloon was carefully chosen in order to avoid overstretching the vessel wall. Each patient had been given chewable aspirin (324 mg daily) and IV heparin before cardiac catheterization. Before angioplasty procedures, intracoronary heparin (10,000 IU) had been given to each patient. Patients did not receive any further heparin and were treated with ticlopidine for 2 weeks and aspirin indefinitely after the intervention. Procedural success was defined as a residual stenosis of < 30% with Thrombolysis in Myocardial Infarction (TIMI) grade 3 flow.13


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  		Table 1. Guiding Catheters and Guidewires Used for PTCA*

 

   Results
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 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 References
 
Baseline Characteristics of Patients
The baseline characteristics of the patients are presented in Table 2 . The patients’ ages ranged from 62 to 80 years, and five of the seven patients (71.4%) were men. Coronary risk factors included the following: hypertension, 100%; diabetes mellitus, 28.6%; smoking, 57.1%; and hypercholesterolemia, 57.1%. Three of the seven patients had had recent inferior wall myocardial infarctions (occurring 10 days before admission) without thrombolytic therapy. They had developed recurrent angina and were transferred to our hospital for further management. Three patients had had a new onset of chest pain at rest and were admitted to our hospital for cardiac catheterization. The other patient (patient 3) experienced acute anterior wall myocardial infarction with a Killip III classification, and coronary angiography showed triple-vessel coronary artery disease. Patient 3 received primary stenting to the LAD, because the coronary flow was finally only achieved to TIMI grade 2 flow (slow-flow phenomenon); therefore, intra-aortic balloon pump (IABP) support was used for this patient. However, chest pain recurred after the intervention in this patient, with ECG-documented horizontal ST-segment depression in the inferior leads. Repeated coronary angiography revealed that the LAD flow had been achieved to TIMI grade 3 flow. It was considered that the recurrent chest pain resulted from inferior wall ischemia; therefore, PTCA to the RCA was performed.


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  		Table 2. Baseline Characteristics and Angiographic Data of the Seven Patients*

 
Angiographic Results
Under fluoroscopy, calcification in the aortic roots in three patients and in the lesion sites in five patients was observed (Table 3 ). The coronary arterial stenoses are summarized in Table 3 . Retrograde dissection to the right CSV occurred in six patients during PTCA to the RCA (Fig 1 ), including four by balloon inflations, one by guiding catheter, and one by a thrombectomy system (AngioJet Rheolytic Thrombectomy System; Possis Medical Inc; Minneapolis, MN) (Table 4 ). Dissection of the LAD with retrograde extension to the left main coronary artery (LMCA) and, finally, to the left CSV by balloon inflation occurred in one patient (Fig 2 and Table 4 ).


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  		Table 3. Angiographic Results in the Seven Patients*

 


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  		Figure 1. Case 4. Top left, A: right coronary angiography demonstrated a total occlusion of the mid-RCA (black arrowhead). Top middle, B: inflation with suitably sized balloon. Top right, C: dissection was observed after dilatation (black arrowheads). Middle left, D: after several dye injections, severe antegrade dissection was noted with delayed coronary flow (black arrows). Middle, E: during the procedure, retrograde dissection to the right CSV with persistent dye stasis was observed (black arrowheads). Middle right, F: altogether, three stents were successfully implanted in the RCA with complete dye clearance of the right CSV. Bottom left, H: 1-year coronary angiographic follow-up showed stenosis of the ostial RCA (black arrowheads). Bottom right, I: left ventriculogram showed good left ventricular performance.

 

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  		Table 4. Characteristics of Dissections, Method of Management, and Clinical Outcome*

 


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  		Figure 2. Case 5. Top left, A: right anterior oblique cranial view demonstrated a severe stenosis of the proximal LAD (black arrow heads). Top middle, B: inflation with a suitably sized balloon. Top right, C: after dilatation, a retrograde dissection of the whole LMCA was noted (black arrows). Middle left, D: retrograde dissection from the distal to the ostial LMCA was more clearly observed by right anterior oblique cranial view (white arrowheads). Middle, E: persistent dye stasis of CSV (black arrowheads). Middle right, F: a repeat coronary angiogram 3 months after surgery revealed a complete healing of the dissection (black arrowheads). Bottom, G: The operative finding: the discoloration and hemorrhagic spots (black arrowheads) along the greater curvature of the ascending aorta indicated an aortic dissection.

 
The retrograde dissection remained localized to the CSV in five of the seven patients (Table 4) . In two of the seven patients (patients 3 and 5), the final angiographic results revealed that the dye was only persistently static in the CSV (Fig 2) . However, after the interventional procedure, retrograde dissection further extending to the ascending aorta was observed by echocardiography (patient 3) and operative findings (patient 5) (Fig 2 , bottom, G).

We observed that the characteristics of dissection of the RCA always extended bidirectionally (antegrade and retrograde). It rapidly and spontaneously propagated within a few minutes, and the dissection could be accelerated by contrast injection. The speed of propagation was the most rapid in the patients who had IABP support (patients 3 and 5).

Angioplasty Results and In-hospital Outcome
A stent was successfully deployed to the RCA and was completely sealed off from the retrograde dissection of the right CSV in five patients. Finally, right coronary angiographies showed TIMI grade 3 flow in these patients (Fig 1) . Non-Q-wave myocardial infarction occurred in three of these five patients (Table 4) . However, their clinical courses were smooth, and no further complications were observed in these patients. They were discharged uneventfully several days after admission. However, in another patient with RCA dissection (patient 3), the procedure was aborted due to a dislodged wire that finally crossed into a false lumen. Transthoracic echocardiography was performed, and the result showed no pericardial effusion; however, retrograde dissection to the ascending aorta was noted. Acute inferior wall myocardial infarction occurred in this patient (documented by ECG). The family and patient refused emergency surgery, and the patient died in refractory ventricular tachycardia and ventricular fibrillation in the cardiac care unit 2 h after the procedure, with transthoracic echocardiography still revealing no pericardial effusion or aortic insufficiency at that time.

The patient who had experienced dissection of the LAD with retrograde extension to the LMCA and the left CSV under IABP support had stable hemodynamics and TIMI grade 3 flow of the LAD, and she was sent for emergency surgery in consideration of LMCA dissection and severe triple-vessel disease. She was discharged uneventfully 10 days after admission.

Long-term Prognosis
All of these six patients who were discharged from our hospital are still alive. Six months later, a repeat 201Tl single photon emission computed tomography study showed no myocardial perfusion defect in patients 1 and 2. Coronary angiography was repeated in patients 4 and 6, and the findings showed restenosis of the RCA. Left coronary angiography showed complete healing of the LAD and the LMCA, and no false lumen was opacified on the aortogram in patient 5. Patient 7 is still asymptomatic while receiving medical therapy.


   Discussion
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
References
 
Increasing operator experience in the past 2 decades and rapid refinements in interventional devices in recent years have led interventional cardiologists to attempt percutaneous treatments of complex lesions4 6 14 15 that were formerly considered to be contraindicated (eg, in LMCA disease) and regarded as having a low success rates and high complication rates (eg, saphenous vein graft lesions and ostial and bifurcation lesions). These may be the reasons why the rate of procedure-related complications is the same as it was in the 1980s.16

Various complications during percutaneous coronary revascularization have been reported in the literature,16 however, extensive dissection of coronary arteries with retrograde dissection to the CSV during PTCA, as occurred in our patients, has rarely been reported.10 17 18 19 20 21 22 23 The etiologies of coronary dissection complicating PTCA have been emphasized due to the use of rigid wires, forceful manipulations of guiding catheters and balloon catheters, and vigorous contrast medium injections.10 17 18 19 20 21 22 However, the exact mechanism responsible for the propagation of dissection and the occurrence of aortic dissection remains to be established. We think that two mechanisms could be responsible for this distinctive complication in our patients. (1) Contrast injections caused an already existing dissection to progress. This mechanism, derived from the angiographic observations in our patients also was hypothesized by Perez-Castellano and colleagues11 and other authors.20 22 (2) The shearing forces of blood flow during systole and diastole could also probably explain the antegrade and retrograde propagation of the dissection. This is just like the mechanism that causes an aortic dissection in a hypertensive patient. Moles et al18 had suggested that the entry ports that were created by mechanical trauma and/or forceful injection of contrast medium into the subintimal space had already been exposed to the aortic bloodstream, which, in turn, contributed to the subsequent extension of the dissection. This reasonable explanation further supports our second hypothesis. These two mechanisms support the theory, which had been suggested by Perez-Castellano et al,11 that dissection of the right CSV always results from a retrograde extension of a dissection of the RCA and could be extrapolated to explain the retrograde dissection of the left CSV.

Limited pathophysiologic variables have been reported as predisposing factors10 17 19 21 23 of aortocoronary dissection during PTCA. However, other factors also should be considered as potential risk factors of this complication. We suggest that several factors that already existed might have played an important role in the appropriateness of dissection for patients. First, calcification was observed in the aortic roots and the lesion sites in more than half of our patients (Table 4) . This means that they had lost considerable elastic property and had brittle characteristics. Second, all of our patients were > 60 years old and had hypertension (Table 2) . This aging process and hypertension might have accelerated medial cystic degeneration of the CSV and media of the aorta, in turn leading to a greater probability of dissection. Third, myocardial infarction had recently occurred in three of the seven patients, and the infarcted vessels were still healing. This inflammatory process could have led the vessel wall to be tender with a tendency to dissection during PTCA. Finally, the IABP support that was implanted in two of the seven patients had augmented the diastolic pressure. This may have aggravated the antegrade and retrograde dissections. The progression of the dissection caused by IABP support was first suspected by Ochi et al21 and was further supported by observations of our two patients who had the IABP support (patients 3 and 5).

There are reports of 24 cases (including our seven cases) of retrograde dissection to the aorta complicated by diagnostic catheterization or interventional procedure (Tables 4 , 5 ). Previously, when stents were not available, a conservative management strategy was the first option, especially for stable patients.24 25 Today, even though stents are currently used, there still are different opinions regarding management of this iatrogenic complication (Table 5) . Perez-Castellano et al11 suggested that conservative treatment is a suitable method for CSV dissections that remain localized during catheterization because they tend to spontaneously resolve in the first month. However, it should be noted that in the study of Perez-Castellano et al11 the number of cases was very low (ie, only four cases). Furthermore, in two of their four cases (cases 1 and 4), after stents were successfully implanted, the dissections were tacked back by the stents and no further complications were noted. Conversely, conservative treatment led to reinfarction (case 2), infarction,25 and death18 and to a complication of retrograde aortic dissection that could not be conservatively treated (case 3), like other similar reports,17 19 20 21 led to emergency surgery. Furthermore, our experience increased our understanding that conservative treatment would lead to a complete compromise of the coronary flow, resulting in myocardial ischemia and, in turn, the development of fatal arrhythmia and sudden cardiac death (like our patient 3). Therefore, caution should be used when extrapolating the results of this study as a reference before deciding how to manage patients with the same problem. We suggest that, when it is possible, coronary stenting is a preferable method in these cases. Because successful coronary stenting can break down the dissection route, propagation of aortic dissection can be prevented. This subsequently leads to stabilization of the aortic dissection, and, in turn, to the avoidance of surgical intervention. This opinion is supported by our cases, the two cases of Perez-Castellano et al,11 and previous reports,19 22 because after successful coronary stenting, persistent dye staining of the right CSV disappeared, the coronary flow could be increased to TIMI grade 3 flow, and patients’ conditions were stabilized.


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  		Table 5. Literature Review of Retrograde Dissection of Aorta*

 
It must be realized that at least 25% of reported patients (Tables 4 , 5) who were identified to have retrograde aortic dissection might not be suitable candidates for coronary stenting, especially when the long-term prognosis was put into consideration. This subgroup of patients who always had severe aortic dissections and whose conditions were associated with other complications,10 17 19 20 21 which included acute severe aortic regurgitation, hemopericardium, unstable hemodynamics, intractable chest pain, guidewire failing to cross the occluded lesion, and left main retrograde dissection, inevitably required surgical management. Even so, coronary stenting can still stabilize the patient’s condition and act as a bridge for surgical intervention.19

To the best of our knowledge, LMCA retrograde dissection to the left CSV complicated by PTCA has been rarely reported,17 20 and our case 5 is the third reported case. However, there are reports of 21 cases of retrograde dissection to the right sinus of Valsalva (including our six cases).10 17 18 19 20 21 22 23 24 25 26 We remain uncertain as to why the RCA is more easily dissected retrograde to the right CSV than the LMCA. Furthermore, it is interesting to note that when dissecting aortic aneurysms involve the coronary arteries, the RCA is also the one usually affected.23 The inherent properties of the RCA may predispose the patient to aortocoronary dissection.19 This predisposition also may be due to distinctions in the histologic structures of the LMCA and the RCA. Anatomically, the aorta at the origins of the LMCA and the RCA is 2 to 4 mm in thickness, so the origin (ostium) and first 2 to 4 mm of the LMCA and the RCA are within the aortic wall. However, histologically, the ostium and the first 2 to 4 mm of the LMCA lack adventitia, with aortic smooth muscle arranged perpendicular to and surrounding the ostium. The tunica media of the LMCA is largely made up of more circulatory or spiral smooth muscle cells than the RCA. These cells are arranged in concentric layers with abundant elastic fibers, which could explain the LMCA being more resistant to retrograde dissection.

Retrograde dissection of the CSV is easily diagnosed by coronary angiography, which usually reveals dye staining persistently localized or extending to the entire aorta. When this angiographic finding was observed, the forceful injection of contrast medium should be avoided in order to prevent the propagation of the dissection. Furthermore, stent implantation should be performed as soon as possible because the saving of time is mandatory in this clinical setting. Stenting to the dissection is not a difficult procedure. Our experiences suggest that stents should first be implanted to the distal dissection and finally to the RCA ostium. After a successful sealing off of the entry port, a complete dye clearance of the aortic sinus of Valsalva and normal coronary flow would be observed. These angiographic results usually suggest that the antegrade and the retrograde dissections are broken down and that the aortic dissection is stabilized. A follow-up aortogram 2 months after the procedure usually reveals no residual opacification of the dissected aortic lumen, which further documents the resolution of the aortic dissection. Transesophageal echocardiography is suggested to be a safe and useful tool.18 22 It is equal or even superior to CT scanning or aortograms in recognizing the eventual regression of the aortic dissection, and it has an important role in the diagnosis and follow-up of patients with this condition.10

In conclusion, this study demonstrates that the CSV is not immune to retrograde dissection during interventional procedures. Coronary stenting is able to prevent this life-threatening complication in most of the patients in this clinical setting. The purpose of this study was to delineate the incidence rate, the potential risks, the characteristics, and the mechanisms of formation of the retrograde dissection of the CSV and to clarify the optimal management of these patients with this difficult complication.


   Footnotes
 
Abbreviations: CSV = coronary sinus of Valsalva; IABP = intra-aortic balloon pump; LAD = left anterior descending artery; LMCA = left main coronary artery; PTCA = percutaneous transluminal coronary angioplasty; RCA = right coronary artery; TIMI = Thrombolysis in Myocardial Infarction

Received for publication February 15, 2000. Accepted for publication August 7, 2000.


   References
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 

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