left main coronary artery dissection complicating diagnostic coronary angiography
DESCRIPTION
Left Main Coronary Artery Dissection Complicating Diagnostic Coronary Angiography. Layth A. Mimish MBChB, FRCPC, FACC Medical Director The Cardiovascular Consultant Clinic Jeddah, KSA. I have no conflict of interest pertaining to this presentation. Left Main Coronary Dissection. - PowerPoint PPT PresentationTRANSCRIPT
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Left Main Coronary Artery Dissection
Complicating Diagnostic Coronary
AngiographyLayth A. MimishMBChB, FRCPC, FACC
Medical DirectorThe Cardiovascular Consultant Clinic
Jeddah, KSA
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I have no conflict of interest
pertaining to this presentation
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Left Main Coronary Dissection• Definition and Classification• Incidence• Etiology• Management
Conservative
CABGS
Stenting
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NHLBI Classification
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Left Main Coronary Dissection•Spontaneous•Extension from Aortic Dissection•Complication of Diagnostic Coronary Angiography or Coronary Interventional procedure
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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
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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
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Conservative Treatment
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CABG Vs Medical Therapy
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ACC / AHA Guidelines
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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
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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
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Motality for CABG in Lt Main
NYS Database 1997-2000
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Stent Vs Conventional Rxfor Abrupt Closure or
Symptomatic Dissection
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French Lt Main RegistryMay 2001-June 2002 (11
French Centers)
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French Lt Main Registry
1 Yr Outcome
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French Lt Main Registry
1 Month &1 Yr Outcome
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French Lt Main Registry
1 Month &1 Yr Outcome
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French Lt Main Registry
1 Month &1 Yr Outcome
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IVUS Optimization for Stent Deployment
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DES Vs BMS in Milan6 Month Clinical & Angiographic F/Up
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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)
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DES in Lt Main DiseaseRESEARCH & T-SEARCH
Registry
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LMCA Intervention in AMC
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In Hospital Outcome
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Overall Restenosis rate 7.9%
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6 Months Clinical Outcome
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MACE Free Survival at 1 Year
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Coclusion
•Rapid & thorough assessment
•CV Surgeon involved
•Haemodynamic support
•DES Vs emergency CABGS
•IVUS