İyatrojenik Aort Diseksiyonu
Özet
Girişimsel kardiyoloji alanındaki gelişmeler ile invaziv tanı ve tedavi işlemlerinin sayısının ve çeşidinin oldukça artmasına sekonder olarak iyatrojenik komplikasyonlar artmaktadır. İyatrojenik aort diseksiyonu (İAD) da acil müdahale gerektiren ve yüksek morbidite ile seyredebilen ve girişimsel kardiyolojik işlemler yapan hekimlerin tanı ve tedavisinde bilgi ve becerilere hakim olması gereken önemli bir klinik tablodur. İAD etyolojisinde başı çeken işlemler perkütan koroner işlemler olmakla beraber diğer perkütan işlemler ve cerrahiye bağlı olarak da gelişebilmektedir. Dunning ve arkadaşlarının aort köküne retrograd olarak uzanım gösteren koroner arter diseksiyonlarını sınıflamak için öne sürdüğü sınıflama sistemi mevcuttur. Bu sınıflamaya göre; Sınıf I, koroner küspis ile sınırlı bir fokal diseksiyon olarak tanımlanır. Sınıf II ise koroner küspisi de içerir ve çıkan aorta kadar uzanır ancak uzunluğu 40 mm’den azdır. Sınıf III, koroner küspisden çıkan aortaya 40 mm’den daha fazla uzanır. İyatrojenik aort diseksiyonları, semptom ve klinik olarak aort diseksiyonuna benzer klinik semptom ve bulgular ile seyreder. Girişimsel kardiyak işlemlere bağlı gelişen aorto- koroner diseksiyonlarda ilk amaç koroner arterde gerçek lümendeki akımı korumak ve diseksiyonun büyümesinin engellemek için giriş noktasının kapatılması olmalıdır. Özellikle aorto-koroner diseksiyonlarda acil bail-out stentleme hastaların yönetiminde ilk etapta düşünülmedir. Stent işlem ile diseksiyon kapatılamadığında veya hemodinamik olarak instabilite durumlarında ise cerrahi düşünülmelidir.
With advancements in the field of interventional cardiology, the number and variety of invasive diagnostic and therapeutic procedures have significantly increased, leading to a rise in iatrogenic complications. Iatrogenic aortic dissection (IAD) is an urgent condition with high morbidity that requires prompt intervention. Physicians performing interventional cardiological procedures must be knowledgeable and skilled in diagnosing and treating this critical clinical scenario. The leading procedures in the etiology of IAD are percutaneous coronary interventions, though it can also develop due to other percutaneous procedures and surgeries. There is a classification system proposed by Dunning and colleagues for classifying coronary artery dissections that extend retrogradely to the aortic root. According to this classification: Class I is defined as a focal dissection limited to the coronary cusp. Class II includes the coronary cusp and extends to the ascending aorta but is less than 40 mm in length. Class III extends from the coronary cusp to more than 40 mm into the ascending aorta. Iatrogenic aortic dissections present with clinical symptoms and findings similar to those of aortic dissection. In cases of aorto-coronary dissection resulting from interventional cardiac procedures, the primary goal should be to maintain flow in the true lumen of the coronary artery and to prevent the extension of the dissection by sealing the entry point. In particular, emergency bail-out stenting should be considered as the initial management strategy for aorto-coronary dissections. If the dissection cannot be sealed with stenting or in cases of hemodynamic instability, surgical intervention should be considered.
Referanslar
Eshtehardi, P., P. Adorjan, M. Togni, et al., Iatrogenic left main coronary artery dissection: incidence, classification, management, and long-term follow-up. American heart journal, 2010. 159(6): p. 1147-1153. doi: 10.1016/j.ahj.2010.03.012
Liao, M.-T., S.-C. Liu, J.-K. Lee, et al., Aortocoronary dissection with extension to the suprarenal abdominal aorta: a rare complication after percutaneous coronary intervention. JACC: Cardiovascular Interventions, 2012. 5(12): p. 1292-1293. doi: 10.1016/j.jcin.2012.06.027
Dunning, D.W., J.K. Kahn, E.T. Hawkins, et al., Iatrogenic coronary artery dissections extending into and involving the aortic root. Catheterization and Cardiovascular Interventions, 2000. 51(4): p. 387-393. doi: 10.1002/1522-726x(200012)51:4<387::aid-ccd3>3.0.co;2-b
Gómez-Moreno, S., M. Sabaté, P. Jiménez-Quevedo, et al., Iatrogenic dissection of the ascending aorta following heart catheterisation: incidence, management and outcome. Eurointervention: Journal of Europcr in Collaboration with the Working Group on Interventional Cardiology of the European Society of Cardiology, 2006. 2(2): p. 197-202.
Yip, H.-K., C.-J. Wu, K.-H. Yeh, et al., Unusual complication of retrograde dissection to the coronary sinus of valsalva during percutaneous revascularization: a single-center experience and literature review. Chest, 2001. 119(2): p. 493-501. doi: 10.1378/chest.119.2.493
López-Mínguez, J.R., V. Climent, S. Yen-Ho, et al., Structural features of the sinus of valsalva and the proximal portion of the coronary arteries: their relevance to retrograde aortocoronary dissection. Revista Española de Cardiología (English Edition), 2006. 59(7): p. 696-702. doi: 10.1157/13091371
Nie, S.-P. and X. Wang, Identification and Management of Iatrogenic Aortocoronary Dissection. Cardiovascular Innovations and Applications, 2016. 1(3): p. 343-350. doi: 10.15212/CVIA.2016.0018
Gur, M., R. Yilmaz, R. Demirbag, et al., Large atherosclerotic plaque related severe right coronary artery dissection during coronary angiography. The international journal of cardiovascular imaging, 2006. 22: p. 321-325. doi: 10.1007/s10554-005-9036-9
Stanger, O., T. Schachner, B. Gahl, et al., Type A aortic dissection after nonaortic cardiac surgery. Circulation, 2013. 128(15): p. 1602-1611. doi: 10.1161/CIRCULATIONAHA.113.002603
Ram, H., S. Dwarakanath, A.E. Green, et al., Iatrogenic aortic dissection associated with cardiac surgery: a narrative review. Journal of Cardiothoracic and Vascular Anesthesia, 2021. 35(10): p. 3050-3066. doi: 10.1053/j.jvca.2020.07.084
Walther, T., C.W. Hamm, G. Schuler, et al., Perioperative results and complications in 15,964 transcatheter aortic valve replacements: prospective data from the GARY registry. Journal of the American College of Cardiology, 2015. 65(20): p. 2173-2180. doi: 10.1016/j.jacc.2015.03.034
Langer, N.B., N.B. Hamid, T.M. Nazif, et al., Injuries to the aorta, aortic annulus, and left ventricle during transcatheter aortic valve replacement: management and outcomes. Circulation: Cardiovascular Interventions, 2017. 10(1): p. e004735. doi: 10.1161/CIRCINTERVENTIONS.116.004735
Clayton, B., G. Morgan-Hughes, and C. Roobottom, Transcatheter aortic valve insertion (TAVI): a review. The British journal of radiology, 2014. 87(1033): p. 20130595. doi: 10.1259/bjr.20130595
Neuhauser, B., B.V. Czermak, J. Fish, et al., Type A dissection following endovascular thoracic aortic stent-graft repair. Journal of Endovascular Therapy, 2005. 12(1): p. 74-81. doi: 10.1583/04-1369.1
Piffaretti, G., G. Mariscalco, M. Tozzi, et al., Acute iatrogenic type A aortic dissection following thoracic aortic endografting. Journal of vascular surgery, 2010. 51(4): p. 993-999. doi: 10.1016/j.jvs.2009.10.105
Jacobs, L.E., M. Fraifeld, M.N. Kotler, et al., Aortic dissection following intraaortic balloon insertion: recognition by transesophageal echocardiography. American Heart Journal, 1992. 124(2): p. 537-540. doi: 10.1016/0002-8703(92)90631-5
Hurwitz, L.M. and P.C. Goodman, Intraaortic balloon pump location and aortic dissection. American Journal of Roentgenology, 2005. 184(4): p. 1245-1246. doi: 10.2214/ajr.184.4.01841245
Isner, J.M., S.R. Cohen, R. Virmani, et al., Complications of the intraaortic balloon counterpulsation device: clinical and morphologic observations in 45 necropsy patients. The American Journal of Cardiology, 1980. 45(2): p. 260-268. doi: 10.1016/0002-9149(80)90644-x
Williams, M.L., S. Sheng, J.S. Gammie, et al., Aortic dissection as a complication of cardiac surgery: report from the Society of Thoracic Surgeons database. The Annals of thoracic surgery, 2010. 90(6): p. 1812-1817. doi: 10.1016/j.athoracsur.2010.05.023
Fleck, T., M. Ehrlich, M. Czerny, et al., Intraoperative iatrogenic type A aortic dissection and perioperative outcome. Interactive Cardiovascular and Thoracic Surgery, 2006. 5(1): p. 11-14. doi: 10.1016/j.athoracsur.2010.05.023
Westenfield, K., S. Mackey-Bojack, Y.L. Wang, et al., Iatrogenic aortic dissection of the descending aorta after percutaneous coronary intervention. The British Journal of Cardiology, 2022. 29(2). doi: 10.5837/bjc.2022.014
Tabry, I., E. Costantini, E. Reyes, et al. Early postoperative acute aortic dissection, the leading cause of sudden death after cardiac surgery? Critical role of the computed tomography scan. in The Heart Surgery Forum. 2003.
Iglesias, D.G., M.M. Fernández, F.L. Iglesias, et al., Iatrogenic aortic dissection: One or more entities? The Annals of Thoracic Surgery, 2016. 101(1): p. 414-415. doi: 10.1016/j.athoracsur.2015.07.036
Núñez-Gil, I.J., D. Bautista, E. Cerrato, et al., Incidence, management, and immediate-and long-term outcomes after iatrogenic aortic dissection during diagnostic or interventional coronary procedures. Circulation, 2015. 131(24): p. 2114-2119. doi: 10.1161/CIRCULATIONAHA.115.015334
Ruchat, P., M. Hurni, F. Stumpe, et al., Acute ascending aortic dissection complicating open heart surgery: cerebral perfusion defines the outcome. European journal of cardio-thoracic surgery, 1998. 14(5): p. 449-452. doi: 10.1016/s1010-7940(98)00224-3
Türköz, R., O. Gulcan, L. Oguzkurt, et al., Successful repair of iatrogenic acute aortic dissection with cerebral malperfusion. The Annals of thoracic surgery, 2006. 81(1): p. 345-347. doi: 10.1016/j.athoracsur.2004.10.005
Hwang, H.Y., D.S. Jeong, K.-H. Kim, et al., Iatrogenic type A aortic dissection during cardiac surgery. Interactive CardioVascular and Thoracic Surgery, 2010. 10(6): p. 896-899. doi: 10.1510/icvts.2009.231001
Referanslar
Eshtehardi, P., P. Adorjan, M. Togni, et al., Iatrogenic left main coronary artery dissection: incidence, classification, management, and long-term follow-up. American heart journal, 2010. 159(6): p. 1147-1153. doi: 10.1016/j.ahj.2010.03.012
Liao, M.-T., S.-C. Liu, J.-K. Lee, et al., Aortocoronary dissection with extension to the suprarenal abdominal aorta: a rare complication after percutaneous coronary intervention. JACC: Cardiovascular Interventions, 2012. 5(12): p. 1292-1293. doi: 10.1016/j.jcin.2012.06.027
Dunning, D.W., J.K. Kahn, E.T. Hawkins, et al., Iatrogenic coronary artery dissections extending into and involving the aortic root. Catheterization and Cardiovascular Interventions, 2000. 51(4): p. 387-393. doi: 10.1002/1522-726x(200012)51:4<387::aid-ccd3>3.0.co;2-b
Gómez-Moreno, S., M. Sabaté, P. Jiménez-Quevedo, et al., Iatrogenic dissection of the ascending aorta following heart catheterisation: incidence, management and outcome. Eurointervention: Journal of Europcr in Collaboration with the Working Group on Interventional Cardiology of the European Society of Cardiology, 2006. 2(2): p. 197-202.
Yip, H.-K., C.-J. Wu, K.-H. Yeh, et al., Unusual complication of retrograde dissection to the coronary sinus of valsalva during percutaneous revascularization: a single-center experience and literature review. Chest, 2001. 119(2): p. 493-501. doi: 10.1378/chest.119.2.493
López-Mínguez, J.R., V. Climent, S. Yen-Ho, et al., Structural features of the sinus of valsalva and the proximal portion of the coronary arteries: their relevance to retrograde aortocoronary dissection. Revista Española de Cardiología (English Edition), 2006. 59(7): p. 696-702. doi: 10.1157/13091371
Nie, S.-P. and X. Wang, Identification and Management of Iatrogenic Aortocoronary Dissection. Cardiovascular Innovations and Applications, 2016. 1(3): p. 343-350. doi: 10.15212/CVIA.2016.0018
Gur, M., R. Yilmaz, R. Demirbag, et al., Large atherosclerotic plaque related severe right coronary artery dissection during coronary angiography. The international journal of cardiovascular imaging, 2006. 22: p. 321-325. doi: 10.1007/s10554-005-9036-9
Stanger, O., T. Schachner, B. Gahl, et al., Type A aortic dissection after nonaortic cardiac surgery. Circulation, 2013. 128(15): p. 1602-1611. doi: 10.1161/CIRCULATIONAHA.113.002603
Ram, H., S. Dwarakanath, A.E. Green, et al., Iatrogenic aortic dissection associated with cardiac surgery: a narrative review. Journal of Cardiothoracic and Vascular Anesthesia, 2021. 35(10): p. 3050-3066. doi: 10.1053/j.jvca.2020.07.084
Walther, T., C.W. Hamm, G. Schuler, et al., Perioperative results and complications in 15,964 transcatheter aortic valve replacements: prospective data from the GARY registry. Journal of the American College of Cardiology, 2015. 65(20): p. 2173-2180. doi: 10.1016/j.jacc.2015.03.034
Langer, N.B., N.B. Hamid, T.M. Nazif, et al., Injuries to the aorta, aortic annulus, and left ventricle during transcatheter aortic valve replacement: management and outcomes. Circulation: Cardiovascular Interventions, 2017. 10(1): p. e004735. doi: 10.1161/CIRCINTERVENTIONS.116.004735
Clayton, B., G. Morgan-Hughes, and C. Roobottom, Transcatheter aortic valve insertion (TAVI): a review. The British journal of radiology, 2014. 87(1033): p. 20130595. doi: 10.1259/bjr.20130595
Neuhauser, B., B.V. Czermak, J. Fish, et al., Type A dissection following endovascular thoracic aortic stent-graft repair. Journal of Endovascular Therapy, 2005. 12(1): p. 74-81. doi: 10.1583/04-1369.1
Piffaretti, G., G. Mariscalco, M. Tozzi, et al., Acute iatrogenic type A aortic dissection following thoracic aortic endografting. Journal of vascular surgery, 2010. 51(4): p. 993-999. doi: 10.1016/j.jvs.2009.10.105
Jacobs, L.E., M. Fraifeld, M.N. Kotler, et al., Aortic dissection following intraaortic balloon insertion: recognition by transesophageal echocardiography. American Heart Journal, 1992. 124(2): p. 537-540. doi: 10.1016/0002-8703(92)90631-5
Hurwitz, L.M. and P.C. Goodman, Intraaortic balloon pump location and aortic dissection. American Journal of Roentgenology, 2005. 184(4): p. 1245-1246. doi: 10.2214/ajr.184.4.01841245
Isner, J.M., S.R. Cohen, R. Virmani, et al., Complications of the intraaortic balloon counterpulsation device: clinical and morphologic observations in 45 necropsy patients. The American Journal of Cardiology, 1980. 45(2): p. 260-268. doi: 10.1016/0002-9149(80)90644-x
Williams, M.L., S. Sheng, J.S. Gammie, et al., Aortic dissection as a complication of cardiac surgery: report from the Society of Thoracic Surgeons database. The Annals of thoracic surgery, 2010. 90(6): p. 1812-1817. doi: 10.1016/j.athoracsur.2010.05.023
Fleck, T., M. Ehrlich, M. Czerny, et al., Intraoperative iatrogenic type A aortic dissection and perioperative outcome. Interactive Cardiovascular and Thoracic Surgery, 2006. 5(1): p. 11-14. doi: 10.1016/j.athoracsur.2010.05.023
Westenfield, K., S. Mackey-Bojack, Y.L. Wang, et al., Iatrogenic aortic dissection of the descending aorta after percutaneous coronary intervention. The British Journal of Cardiology, 2022. 29(2). doi: 10.5837/bjc.2022.014
Tabry, I., E. Costantini, E. Reyes, et al. Early postoperative acute aortic dissection, the leading cause of sudden death after cardiac surgery? Critical role of the computed tomography scan. in The Heart Surgery Forum. 2003.
Iglesias, D.G., M.M. Fernández, F.L. Iglesias, et al., Iatrogenic aortic dissection: One or more entities? The Annals of Thoracic Surgery, 2016. 101(1): p. 414-415. doi: 10.1016/j.athoracsur.2015.07.036
Núñez-Gil, I.J., D. Bautista, E. Cerrato, et al., Incidence, management, and immediate-and long-term outcomes after iatrogenic aortic dissection during diagnostic or interventional coronary procedures. Circulation, 2015. 131(24): p. 2114-2119. doi: 10.1161/CIRCULATIONAHA.115.015334
Ruchat, P., M. Hurni, F. Stumpe, et al., Acute ascending aortic dissection complicating open heart surgery: cerebral perfusion defines the outcome. European journal of cardio-thoracic surgery, 1998. 14(5): p. 449-452. doi: 10.1016/s1010-7940(98)00224-3
Türköz, R., O. Gulcan, L. Oguzkurt, et al., Successful repair of iatrogenic acute aortic dissection with cerebral malperfusion. The Annals of thoracic surgery, 2006. 81(1): p. 345-347. doi: 10.1016/j.athoracsur.2004.10.005
Hwang, H.Y., D.S. Jeong, K.-H. Kim, et al., Iatrogenic type A aortic dissection during cardiac surgery. Interactive CardioVascular and Thoracic Surgery, 2010. 10(6): p. 896-899. doi: 10.1510/icvts.2009.231001
