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 Definition and Classification Incidence Etiology Management Conservative CABGS Stenting

NHLBI Classification

Left Main Coronary Dissection Spontaneous Extension from Aortic Dissection Complication of Diagnostic Coronary Angiography or Coronary Interventional procedure

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

Left Main Coronary Dissection Sone’s initial series 4200 diagnostic procedures, 1 reported dissection Massachusetts General Hospital 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 cases, incidence 0.02 for diagnostic angiography, and 0.07% for PCI Under-reported, with severity varying from type A to severe aortic root dissection

Conservative Treatment

CABG Vs Medical Therapy

ACC / AHA Guidelines

Clinical Outcomes with CABG in Lt. Main Disease 18 Centers Jan 2001-June ,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

OPCAB in LMCA Disease Off PumpOn Pump n 2731,163 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

Motality for CABG in Lt Main NYS Database

Stent Vs Conventional Rx for Abrupt Closure or Symptomatic Dissection

French Lt Main Registry May 2001-June 2002 (11 French Centers)

French Lt Main Registry 1 Yr Outcome

French Lt Main Registry 1 Month &1 Yr Outcome

IVUS Optimization for Stent Deployment

DES Vs BMS in Milan 6 Month Clinical & Angiographic F/Up

DES in Lt Main Disease RESEARCH & 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 ( )

DES in Lt Main Disease RESEARCH & T-SEARCH Registry

LMCA Intervention in AMC

In Hospital Outcome

Overall Restenosis rate 7.9%

6 Months Clinical Outcome

MACE Free Survival at 1 Year

Coclusion Rapid & thorough assessment CV Surgeon involved Haemodynamic support DES Vs emergency CABGS IVUS