Treatment of Iatrogenic Coronary Artery Dissection in Resource Constraint in Cath-Lab, A Retrospective Study

Introduction: Coronary Artery Dissection is a well-known serious complication of invasive procedures (e.g. coronary angiography, balloon angioplasty and surgical cardioplegia) and is due to mechanical injury of the arterial wall by interventional devices used during procedures needing skilled operator to manage it timely. Objective: We wanted to look at these large tears that can dramatically affect blood flow and result in severe complications to understand where they happen most and how efficient are we at managing them for our patients in limited resources of the Cath-labs in developing countries. Methods: We reviewed the record of 28 (3.4%) cases of large dissection found in 806 patients who underwent coronary angioplasty in Cath lab of Cardiology Department of Dow University of Health Sciences Karachi. We analyzed as per American College of Cardiology/American Heart Association (ACC/AHA) criteria of the type of lesion, chronic total occlusion, calcification, intra-procedural dissection, and vessel site, related complications and management strategies. Results: Among the 806 patients that underwent per-cutaneous coronary intervention during 3 years (2014-2017) period at Cath-lab of Cardiology Department of Dow University of Health Sciences Karachi, 28 (3.4%) patients were found to have extensive dissection. Out of 10 patients who had immediate angioplasty and stenting for closure of dissection 8 patients were successfully treated and 2 (7.1) died during procedures. 8 (28.5%) needed immediate coronary artery bypass surgery. 10 (35.7%) out of the 28 (3.4%) patients were managed by further hospitalization with medical treatment out of them 3 patients needed angioplasty procedures. There were no late deaths. Conclusion: Coronary artery dissection remains a common occurrence during PCI since pre-stent procedures and clinical sequelae have been minimized by the routine use of coronary stents. Rapid recognition and attention to the angiographic appearance of the dissection is essential to the successful management of this complication. None the less, patients with extensive dissection who are free from the manifestation at the end of the procedure can be managed conservatively. Attempts should be made to stabilize extensive dissection during coronary angioplasty so that surgical intervention can be delayed or avoided altogether if possible.