PCI Complications: Dissection
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Editors-In-Chief: Alexandra Almonacid M.D.[1] and Jeffrey J. Popma M.D.[2]
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Incidence:
- Significant vessel wall disruptions resulting in reduced anterograde flow and lumen narrowing is a relatively (< 3%) uncommon complication (1).
- Significant residual dissections: 1.7 % of patients undergoing PCI
Etiology
- Mechanisms for disrupting the coronary vessel
- Barotraumas-induced dissections,
- Guiding catheter dissections
Classification System
The National Heart, Lung and Blood Institute (NHLBI) coronary dissection criteria assign according the severity of coronary dissection following PCI (Table 1), with the prognostic implications of the coronary dissection depending on extension into the media and adventitia, its axial length, presence of contrast staining, and effect on antrograde coronary perfusion.
Difficulties can be present when assessing the angiographic residual lumen in the presence of coronary dissection due to the frame-to-frame lumen diameter changes using two-dimensional imaging; intravascular ultrasound (IVUS) may be more accurate strategy to provide the true circumference lumen dimensions.
Table 1 • STANDARDIZED CRITERIA FOR POSTPROCEDURAL LESION MORPHOLOGY
- Abrupt closure: Obstruction of contrast flow (TIMI 0 or 1) in a dilated segment with previously documented anterograde flow
- Ectasia: A lesion diameter greater than the reference diameter in one or more areas
- Luminal irregularities: Arterial contour that has a “sawtooth pattern” consisting of opacification but not fulfilling the criteria for dissection or intracoronary thrombus
- Intimal flap: A discrete filling defect in apparent continuity with the arterial wall
- Thrombus: Discrete, mobile angiographic filling defect with or without contrast staining
NHLBI Classification Scheme for Dissection
A Small radiolucent area within the lumen of the vessel
B Linear, nonpersisting extravasation of contrast
C Extraluminal, persisting extravasation of contrast
D Spiral-shaped filling defect
E Persistent lumen defect with delayed anterograde flow
F Filling defect accompanied by total coronary occlusion
Length:Measure end-to-end for type B through F dissections
Staining: Persistence of contrast within the dissection after washout of contrast from the remaining portion of the vessel
- Perforation Localized: Extravasation of contrast confined to the pericardial space immediately surrounding the artery and not associated with clinical tamponade
- Nonlocalized: Extravasation of contrast with a jet not localized to the pericardial space, potentially associated with clinical tamponade
- Side branch loss: TIMI 0, 1, or 2 flow in a side branch > 1.5 mm in diameter which previously had TIMI 3 flow
- Distal embolization: Migration of a filling defect or thrombus to distally occlude the target vessel or one of its branches
- Coronary spasm: Transient or permanent narrowing >50% when a <25% stenosis was previously noted
+National Heart, Lung, and Blood Institute classification system for coronary dissection.
Treatment
- Most intra-procedural dissections can be treated promptly with stenting,
References
Acknowledgement and Attribution Regarding Sources of Content
Some of the initial content on this page may be incorporated in part from copyleft sources in the public domain including wikis such as Wikipedia and AskDrWiki. Drug information for patients came from the The National Library of Medicine. Infectious disease information may have come from the Centers for Disease Control (CDC). Differential Diagnoses are drawn from clinicians as well as an amalgamation of 3 sources: 1.The Disease Database; 2. Kahan, Scott, Smith, Ellen G. In A Page: Signs and Symptoms. Malden, Massachusetts: Blackwell Publishing, 2004:3; 3. Sailer, Christian, Wasner, Susanne. Differential Diagnosis Pocket. Hermosa Beach, CA: Borm Bruckmeir Publishing LLC, 2002:7 .
