Management of Coronary Dissection During PCI
Coronary artery dissection during PCI requires immediate stenting of the affected segment as the primary management strategy when there is ongoing ischemia, compromised coronary flow, or hemodynamic instability.
Immediate Assessment and Classification
- Assess the severity of dissection based on coronary flow impairment (TIMI flow), hemodynamic stability, and extent of the dissection 1
- Coronary dissections during PCI most commonly occur due to guidewire advancement (30%), stenting (22%), balloon angioplasty (20%), or guide catheter engagement (18%) 1
Management Algorithm Based on Clinical Presentation
For Dissections with Compromised Flow (TIMI 0-2) or Hemodynamic Instability:
- Immediate stenting is indicated to restore vessel patency and prevent progression of the dissection 1, 2
- Consider use of intracoronary glycoprotein IIb/IIIa inhibitors in cases with large thrombus burden, no-reflow, or slow flow to improve procedural success 3
- For extensive dissections, a longer stent or multiple overlapping stents may be necessary to cover the entire dissected segment 2
- In cases of severe dissection with perforation, covered stents may be required 2
For Dissections with Preserved Flow (TIMI 3) and Hemodynamic Stability:
- Consider conservative management if the dissection is limited and not flow-limiting 4
- Monitor closely with serial angiography to ensure stability of the dissection 2
- Be prepared for bailout stenting if there is any deterioration in flow or clinical status 1
Role of Intravascular Imaging
- Intravascular imaging (IVUS or OCT) can help confirm the diagnosis and guide management decisions 5
- OCT-guided PCI for coronary dissection has shown favorable outcomes similar to other ACS etiologies 5
- Caution: Intravascular imaging should be used judiciously as it can potentially worsen the dissection or trigger abrupt vessel closure 3
- Only use intravascular imaging if the decision to proceed with revascularization has already been made 3
Special Considerations
- Dissections starting at the ostium with difficult true lumen identification carry higher risk for abrupt occlusion during PCI 3
- For dissections involving the left main coronary artery, consider emergency CABG if PCI is not feasible or fails 3
- In cases of spontaneous coronary artery dissection (SCAD), PCI has approximately 50% failure rate, even with normal coronary flow at baseline 3, 4
- For chronic total occlusion PCI complicated by perforation, intentional creation of dissection flaps using subintimal tracking and re-entry technique may be considered to seal the perforation 6
Antiplatelet Therapy After Coronary Dissection Management
- For patients receiving drug-eluting stents (DES) during PCI for dissection in the setting of ACS, dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor (ticagrelor or prasugrel preferred) should be given for at least 12 months 3
- For non-ACS indications treated with DES, clopidogrel 75 mg daily should be given for at least 12 months if patients are not at high risk of bleeding 3
- For patients treated with bare-metal stents for non-ACS indications, clopidogrel should be given for a minimum of 1 month and ideally up to 12 months 3
- Consider aspirin 81 mg daily in preference to higher doses after PCI 3
Post-Procedure Monitoring and Follow-up
- Close monitoring is essential as complications can recur 4
- Consider follow-up coronary angiography between 2 and 6 months after PCI for unprotected left main coronary dissections 3
- Monitor for signs of restenosis, which may require repeat intervention 3
Complications and Outcomes
- Coronary dissection during PCI is associated with significant adverse outcomes including death (7% in-hospital, 20% long-term), acute myocardial infarction (9%), and emergency CABG (2%) 1
- Target lesion revascularization rate is approximately 11.3% during long-term follow-up 1
- Technical success rate for PCI in coronary dissection is around 65%, with procedural success of 55% 1