Primary spontaneous coronary artery dissection complicated by iatrogenous aortic dissection: from David procedure to full arterial coronary revascularization

Abstract

Primary spontaneous coronary artery dissection (PSCAD) is an uncommon cause of acute myocardial infarction that can lead to fatal course especially because of non-standardized management. We report the case of a 37-year-old woman who presented with a PSCAD of the right coronary artery. A young woman was addressed to our hospital for a PSCAD of the right coronary artery (RCA). During the coronary angiogram, an iatrogenous type II aortic dissection occurred. She was then scheduled for surgery since ascending aortic diameter after the dissection was measured at 52 mm. A David procedure was made to replace the aortic root. Since weaning from cardiopulmonary bypass (CPB) was easy without ischemic signs in the right territory, we didn't systematically graft the RCA. Thirty minutes after the end of the procedure, a cardiogenic shock occurred witnessing a complete thrombosis of the RCA. CPB was restarted and the RCA was grafted on-pump using a right internal thoracic artery (RITA). The left network was examined and also showed to be dissected. Using the LITA, a T-graft was constructed and the left anterior descending and a marginal branch were grafted, rendering the weaning from CPB possible. Postoperative troponin at day 1 was 93 microg/l. Weaning from inotropic drugs and from intra-aortic balloon pump was possible after four days. Extubation was postponed because of a pulmonary infection due to hemophilus influenzae. It was done at day 14. Echographic control showed no residual aortic insufficiency. CT-scan showed a patent RITA-to-RCA graft but an involution of the LITA graft, along with a healing of the left network. PSCAD is a severe condition and its management is unclear. The grafting of the diseased coronaries can be facilitated by an on-pump technique and the use of a coronary shunt to avoid further ischemia.