Spiral Dissection Research Articles

Case report of spontaneous coronary artery dissection in a 50‑year‑old man

BackgroundSpontaneous Coronary Artery Dissection (SCAD) is an acute coronary event of uncertain origin. SCAD occurs when the coronary artery wall dissects non-traumatically and non-atherosclerotically, leading to the formation of an intramural hematoma or intimal tear, ultimately compressing and restricting the true lumen, or even occluding it. The management of SCAD remains controversial despite modern imaging techniques. In addition to supportive drug therapy, percutaneous coronary intervention (PCI) is another option that can be used as an effective treatment modality.Case presentationWe describe A 50-year-old male with SCAD presented to the hospital emergency department complaining of chest pain. Coronary angiography incidentally showed spiral dissection from the proximal to distal right coronary artery (RCA). Three overlapping coroflex stents were deployed from the distal to the proximal RCA.ConclusionsTo stabilize the coronary artery in Acute Coronary Syndrome (ACS) patients due to SCAD, prompt interventions such as stenting and angioplasty are needed. However, it is necessary to pay attention to the clinical condition of patients and quick diagnosis for the recovery of patients and reduction of complications.

Outcomes of non-flow-limiting spiral dissection after drug-coated balloon angioplasty for de novo femoropopliteal lesions.

Whether drug-coated balloon (DCB) angioplasty would be effective in spiral dissection (SD) lesions with no flow impairment has been thoroughly investigated. The present study sought to assess the clinical outcomes of non-flow-limiting SD after DCB angioplasty for de novo femoropopliteal lesions in patients with symptomatic lower extremity artery disease. This single-center retrospective study enrolled 497 patients with non-flow-limiting SD (n = 92) or non-SD (n = 405) without bailout stenting. The primary endpoint was 1-year primary patency, with the secondary endpoints including freedom from target lesion revascularization (TLR), major adverse limb event (MALE), all-cause death, and 30-day restenosis. The 1-year primary patency and freedom from TLR were significantly lower in the SD group than in the non-SD group (69.8% vs. 83.3%, p = 0.004; 78.7% vs. 93.0%, p = 0.007, respectively). The SD group had a higher incidence of MALE and 30-day restenosis than the non-SD group (24.6% vs. 11.9%, p = 0.001; 4.3% vs. 0.5%, p = 0.002, respectively). All-cause death was comparable. One-year restenosis after SD was associated with chronic limb-threatening ischemia (CLTI) (hazard ratio, 3.36 [95% confidence interval, 1.21-9.36]; p = 0.020), TASC Ⅱ D (hazard ratio, 3.97 [95% confidence interval, 1.02-15.52]; p = 0.047), and residual stenosis ≥50% (hazard ratio, 4.92 [95% confidence interval, 1.01-23.94]; p = 0.048). The incidence of restenosis after SD increased with the number of these risk factors. Despite normal antegrade flow, the 1-year primary patency rate after DCB angioplasty for de novo femoropopliteal lesions was significantly lower in lesions with SD than those without SD. CLTI, TASC II D, and residual stenosis ≥50% were risk factors associated with 1-year restenosis after DCB angioplasty for non-flow-limiting SD lesions.

Abstract 18234: The Fast and the Furious, A Rare Case of RCA Dissection Following a Car Accident in a Male Patient

Introduction: Coronary artery dissection is a rare, but potentially lethal, etiology of chest pain in the emergency department. Dissection is defined as a spontaneous, traumatic, or iatrogenic disruption of the tunica intima, causing blood to accumulate in a false lumen. Coronary artery dissection reportedly has a 0.1% incidence in the general population, occurring most commonly in the LAD, and less commonly in the RCA. Acute myocardial infarction (AMI) following blunt chest trauma has an age predominance of 82% being less than 45 years of age. With a low incidence and abnormal age presentation, an electrocardiogram must be included in the work-up of blunt chest trauma to assess for coronary artery dissection. Case: A 44-year-old male with a history of polysubstance abuse, obesity, and hypertension presented with left hip pain following a motor vehicle accident. The patient had been operating a small motorcycle when he struck a stationary vehicle. He was wearing a helmet but was ejected from the motorcycle, landing on his back. The patient eventually began to experience both right-sided chest pain as well as right-sided neck pain while in the. An electrocardiogram was performed that showed inferior ST-segment elevation with reciprocal ST-segment depression in the lateral leads. Troponins were 42ng/L, 1,465ng/L and 8,170ng/L. Cardiac catheterization revealed a spiral dissection of the RCA extending from the ostium to the mid-segment with TIMI 1 flow. The patient remained on medical management of aspirin, clopidogrel, and heparin and was monitored in intensive care for 48 hours prior to home discharge. Conclusion: Blunt force cardiac injury is an uncommon cause of chest pain and myocardial infarction, and rarer still is RCA dissection. This case highlights the distinct importance of electrocardiograms as a pivotal part of the trauma and chest pain diagnostic reasoning process.

Abstract 15838: To Tear Again: Recurrent and Complicated Spontaneous Coronary Artery Dissection

Background: SCAD is as an infrequent cause of ACS with a predominance affecting a mean age of 42.6 years and 82% of patients being female. SCAD can be classified as primary or secondary, where primary dissections occur spontaneously, and secondary causes involve the aortic root and are a direct consequence of coronary interventions, surgery, or trauma. Case: 26-year-old female with no previous cardiac or significant family history presented with severe mid-sternal chest pain, radiating to both arms and back, and associated with nausea and cold sweats. Cardiovascular exam was unremarkable. Troponins were elevated at 0.18 and 0.59. Echo showed anteroseptal wall hypokinesis, consistent with Takotsubo cardiomyopathy. ECG showed anterolateral ST elevations. The patient went for cardiac catheterization and had spontaneous dissection of the left main into the LAD/diagonal with 100% occlusion of the LAD and 99% occlusion of the ramus/circumflex. Impella device was implanted due to persistent shock, V. fib., and cardiac arrest. Stents were placed in the proximal, mid, and distal LAD, ramus/circumflex, and LCA. The patient had an LVEF of 25%. Follow-up echo showed an LVEF of 30%, with subsequent Impella removal. Following week, LVEF increased to 45-50%. The patient began aspirin 81 mg, atorvastatin 10 mg, bisoprolol 5 mg, prasugrel 10 mg, and rivaroxaban 10 mg. Over the next few years, she had recurrent chest pain, syncope, palpitations, and a non-viable pregnancy at 12 weeks of gestation due to premature bleeding complications. 3 years after the initial SCAD, the patient presented with spiral dissection of the RCA, requiring three stents. LVEF was 30%. She is being managed with aspirin 81 mg, atorvastatin 20 mg, bisoprolol 10 mg, and prasugrel 10 mg. Discussion: The initial age of presentation of this patient makes this case unique. Risk of recurrent SCAD was present in 17% of patients at a median age of 2.8 years after the initial episode. Triggers for recurrent SCAD include extreme emotional/physical stress and pregnancy. Pregnancy it is not recommended in this patient population. Beta-blockade and adequate BP control are mainstay in medical management and reduce the reoccurrence of SCAD.

Spiral dissection of the left coronary artery as a rare and serious complication of coronary angiography: a case report

Background: Iatrogenic spiral dissection of the coronary artery is a rare but serious complication of Coronary angiography (CA). CA is a standard imaging method, which is considered as a safe and commonly used.Aim of the study: To demonstrate a rare complication of CA that significantly changed the patient’s outcome.Material and methods: A retrospective review of the procedure and the patient’s follow-up has been performed.Case report: A 56-year-old woman with type two atrial septal defect complicated by heart failure (HF), complaining of a gradual HF worsening and two episodes of syncope was admitted for preoperative assessment. Prior to cardiac surgery an elective CA revealed no stenoses in coronary arteries, however it was complicated by the spiral dissection of the left main coronary artery continuing towards the left anterior descending artery. Immediate percutaneous coronary angioplasty was performed with a good acute angiographic and clinical result. Subsequently, the patient developed a periprocedural inferolateral myocardial infarction and cardiac arrest due to pulseless electrical activity. Cardiopulmonary resuscitation was ineffective.Conclusion: The take home message of the case presented is that even a relatively safe procedure may be complicated and that less invasive imaging modalities should be considered prior to CA.

An Unusual Presentation ofSCAD ina Young Male Soldier.

Spontaneous coronary artery dissection (SCAD) is a non-atherosclerotic cause of myocardial infarction and sudden cardiac death in young individuals without significant cardiovascular risk factors. The etiology of SCAD appears to be multifactorial and is often precipitated by physical and emotional stress superimposed on underlying arteriopathy, connective tissue disorders, systemic inflammatory disorders, genetic factors, and hormonal influences. There are no current societal guidelines to stratify young soldiers' risk of developing SCAD. Diagnosis typically requires invasive coronary artery angiography which is largely unavailable in stations with limited medical resources. Furthermore, young patients with SCAD often present with atypical cardiac symptoms, such as heartburn leading to the misdiagnosis of gastroesophageal reflux disease and a delay in diagnosis and management. We present a 21-year-old active duty male who was transferred from Okinawa, Japan to a tertiary military medical center for evaluation of hypercoagulable conditions after CT revealed non-obstructing portal venous thrombosis extending to right hepatic vein, splenic vein thrombosis with splenic infarct, and bilateral wedge-shaped renal infarct. Extensive work-up ultimately revealed mid-left anterior descending spiral dissection with transmural infarct of inferior, anteroseptal, and inferoseptal wall resulting in the formation of left ventricular thrombus, subsequently causing thromboembolism to multiple organs. This case demonstrates the ramifications of SCAD when diagnosis and management are delayed and serve as a poignant reminder for all providers to include SCAD in the differential diagnosis for young soldiers with atypical chest pain.

A Rare Case of Acute Myocardial Infarction Due to Coronary Artery Dissection and Heparin-Induced Thrombocytopenia

Background: Although both coronary artery dissection and heparin-induced thrombocytopenia may provoke myocardial infarction, it is extremely rare for both conditions to develop simultaneously in a single patient. We report a case of a 69-year-old woman who sustained a head-on motor vehicle accident with associated chest trauma. Methodology: During a subsequent hospitalization, she was exposed to subcutaneous heparin and developed significant thrombocytopenia. Shortly after that, she was represented with acute myocardial infarction. Result: Coronary angiography revealed a spiral dissection with superimposed thrombosis within the right coronary artery, while laboratory testing confirmed the diagnosis of heparin-induced thrombocytopenia. She was treated with catheter-based thrombectomy and adjunctive direct thrombin inhibitor therapy, followed by three months of systemic anticoagulation with warfarin. Conclusion: To our knowledge, this represents the first published case of a native vessel myocardial infarction due to the combination of coronary artery dissection and heparin-induced thrombocytopenia.

Spontaneous Spiral Dissection of Left Anterior Descending Coronary Artery in a Young Female

The present case is unique and the first to describe the spiral nature of dissection in spontaneous coronary artery dissection in a young female which has not yet been described in the world literature.

Spontaneous Spiral Dissection of the Left Anterior Descending Coronary Artery in a Reformed Smoker

Spontaneous dissection of the coronary artery is a well-known entity in young females with myocardial infarction. We report a rare case of spontaneous spiral dissection of the left anterior descending coronary artery (LAD) in a 62-year-old male with history of smoking for 15 years and who has quit smoking 5 years back. Just like an old age saying “footprints are left behind,” the deleterious conundrum of smoking continues even after years together resulting in a spontaneous dissection in the background of damaged arterial elastic media.

TCTAP C-070 Spiral Dissection of RCA in Procedure of PCI

TCTAP C-070 Spiral Dissection of RCA in Procedure of PCI

Case reports of antegrade and retrograde iatrogenic coronary spiral dissection complicating percutaneous coronary intervention: Keep calm and carry on!

Iatrogenic dissection during PCI represents one of the most fearing complication of interventional cardiology, since abrupt hemodynamic instability and patient compromise may occur related to coronary occlusion. In this emergency situation, different hemodynamic support devices and interventional skills, are needed in order to promptly recover the patient from cardiogenic shock, especially when the left coronary three is involved by the dissection. We report herein two different iatrogenic retrograde, and antegrade dissections, one involving both left anterior descending artery, left circumflex and aortic bulb and the second characterized by abrupt closure of left main associated with severe hemodynamic compromise and ventricular fibrillation storm which required continuous DC shocks, Impella and ECMO devices support to stabilize the patient. Both cases were successfully managed percutaneously. Different techniques and tricks in order to re-open the vessels are described. In case of iatrogenic coronary dissection, a “keep calm and carry on” strategy should be adopted by the interventional cardiologist team in order to solve such dramatic complication.

Influence of Material Model and Aortic Root Motion in Finite Element Analysis of Two Exemplary Cases of Proximal Aortic Dissection.

The risk of type-A dissection is increased in subjects with connective tissue disorders and dilatation of the proximal aorta. The location and extents of vessel wall tears in these patients could be potentially missed during prospective imaging studies. The objective of this study is to estimate the distribution of systolic wall stress in two exemplary cases of proximal dissection using finite element analysis (FEA) and evaluate the sensitivity of the distribution to the choice of anisotropic material model and root motion. FEA was performed for predissection aortas, without prior knowledge of the origin and extents of vessel wall tear. The stress distribution was evaluated along the wall tear in the postdissection aortas. The stress distribution was compared for the Fung and Holzapfel models with and without root motion. For the subject with spiral dissection, peak stress coincided with the origin of the tear in the sinotubular junction. For the case with root dissection, maximum stress was obtained at the distal end of the tear. The FEA predicted tear pressure was 20% higher for the subject with root dissection as compared to the case with spiral dissection. The predicted tear pressure was higher (9-11%) for root motions up to 10 mm. The Holzapfel model predicted a tear pressure that was lower (8-15%) than the Fung model. The FEA results showed that both material response and root motion could potentially influence the predicted dissection pressure of the proximal aorta at least for conditions tested in this study.

Traumatic Coronary Artery Dissection Diagnosed Immediately with Cardiac CT

A young male presented with chest pain after blunt chest wall trauma. Immediate CT coronary angiography demonstrated a spiral dissection of the right coronary artery. CT fractional flow reserve confirmed modest flow limitation so the patient was treated medically. At follow-up CT the vessel had healed and CT fractional flow reserve had normalised.

Dissection-related carotid-cavernous fistula (CCF) following surgical revascularization of chronic internal carotid artery occlusion: a new subtype of CCF and proposed management

BackgroundThe development of carotid-cavernous fistulas (CCFs) during surgical recanalization of chronic internal carotid artery occlusion (ICAO) may be secondary to severe ICA dissection rather than a focal tear of the cavernous ICA seen in typical traumatic CCFs. The purpose of this study is to investigate the causal relationship between the CCFs and severe ICA dissections and to characterize technical outcomes after treatment with stenting.MethodsFive patients underwent treatment with self-expanding stents due to intraprocedural CCF and ICA dissection following surgical removal of ICAO plaque. The stents were telescopically placed via true channel of the dissection. Safety of the procedure was evaluated with 30-day stroke and death rate. Procedural success was determined by the efficacy of CCF obliteration and ICAO recanalization with angiography.ResultsAll CCFs were associated with spiral and long segmental dissection from the cervical to cavernous ICA. After stenting, successful dissection reconstruction with TICI 3 was achieved in all patients, with complete (n = 4) or partial CCF (n = 1) obliteration. No patient had CCF syndrome, stroke, or death during follow-up of 6 to 37 months; but one patient had pulsatile tinnitus, which resolved 1 year later. Angiography at 6 to 24 months demonstrated CCF obliteration in all 5 patients and durable ICA patency in 4 patients.ConclusionsIntraprocedural CCFs with spiral and cervical-to-cavernous ICA dissection during ICAO surgery are dissection-related because of successful obliteration after stenting for dissection reconstruction. Self-expanding stenting through true channel of the dissection, serving as implanting stent-autograft, may be an optimal therapy for the atypical CCF complication from ICAO surgery.

TCTAP C-099 Bifurcation PCI in a Chronic Spontaneous Long Coronary Dissection

### Patient Initials or Identifier Number LY ### Relevant Clinical History and Physical Exam 63 yrs old male Hypertension, Ex-smoker. Admitted in another hospital for anterolateral STEMI. On diagnostic angiography: severe 99% stenosis of proximal LAD and long spontaneous spiral dissection of

The crucial techniques and anatomic markers in transanal total mesorectal excision

Transanal total mesorectal excision (taTME) for rectal cancer is a hot spot in the field of colorectal surgery in recent years, because this technique has the advantages of clear distal margin, early separation of tumor leision, in the treatment of low rectal cancer. However, this technique is not popularized yet, and there are only a few colorectal surgeons who have enough experience. This article shares the experience of taTME in our hospital, including the details of purse string suture, spiral dissection of rectum, and the anatomic markers of anterior and posterior of rectum, conjoined longitudinal muscle and capillary of pelvic nerves locating in pelvic fascia. We sum up the crucial techniques as transanal operation, single port endoscopic technique and mucosal surgical principle (from inside to outside and from bottom to top), aiming to help colorectal surgeons to grasp the essentials of the techniques with initial cases as soon as possible, and to shorten the learning curve, so that more and more patients can benefit.

Complication during Endovascular Intervention: Acute Ischemia of the Lower Extremity as a Result of Spiral Dissection with Antegrade Puncture of the Left Common Femoral Artery

Introduction. Over the past decade, endovascular interventions have become widely used in patients with obliterating atherosclerosis of lower extremity arteries. This is due to the low-trauma nature of the methodology, various technological achievements in the improvement of instruments and the accumulation of operational experience. However, despite all the successes achieved, no intervention is without its complications. In the case of endovascular interventions, complications are most commonly associated with the site of arterial access. One of the most widely-used arterial approaches is retrograde femoral access. However, if an intervention is planned on the femoropopliteal arterial segment, the antegrade femoral approach is generally the method of choice. Among the advantages of antegrade access can be noted the shorter path to the site, better toolkit support and a shorter operation duration. One of the main complications involved in antegrade access is the development of dissection. Although this complication occurs in less than 1% of cases, it carries a threat of critical ischemia of the lower limbs, which may require emergency open surgery up to and including emergency limb amputation.Materials and methods. The paper presents a clinical case of successful treatment of iatrogenic spiral dissection, which occurred following antegrade vascular access. During surgical treatment of this complication, stents were implanted throughout the dissection to “press” the exfoliated layer of the intima.Results. The study presents a case of iatrogenic spiral dissection after antegrade femoral puncture followed by successful endovascular treatment of this complication.Conclusion. Endovascular balloon angioplasty and stenting can be successfully used when iatrogenic dissection develops following antegrade puncture of the right femoral artery, allowing classic “open” surgical intervention to be avoided.

TCTAP C-114 False Lumen Stenting with Spiral Dissection Is Rescued by Retrograde Re-wiring

TCTAP C-114 False Lumen Stenting with Spiral Dissection Is Rescued by Retrograde Re-wiring

Threading the Eye of the Needle: A Challenging Case of Iatrogenic Spiral Coronary Artery Dissection

Catheter induced coronary dissection is an uncommon but potentially catastrophic complication of coronary angiography. We report a case of a 48-year-old female with normal coronary arteries on angiography complicated by extensive catheter induced spiral dissection. Wiring into the true lumen was a formidable challenge as a consequence of the large false lumen obliterating the true lumen. We present management strategies and in particular, highlight the important role of intravascular ultrasound (IVUS) imaging.

TCTAP C-160 Mechanical Rotation less Thrombectomy in Chronic Total Occlusion Lesion Complicated with Spiral Dissection: Whether We Are in Hurry or Not

### Patient initials or identifier number E.L ### Relevant clinical history and physical exam Patient admitted due to chest pain about 2 weeks ago. The patient felt like tightness in left side of her chest. It was felt while doing moderate activity with duration about 5 minutes or less. A week