What is the recommended immediate management of an iatrogenic coronary artery dissection based on the patient’s hemodynamic stability, dissection location, and coronary flow (TIMI grade)?

Treatment of Iatrogenic Coronary Dissection

Immediate Assessment and Risk Stratification

Management of iatrogenic coronary dissection must be guided by three critical factors: hemodynamic stability, presence of anterograde coronary ischemia, and anatomic extent of dissection—with immediate percutaneous intervention indicated for hemodynamically unstable patients or those with compromised coronary flow. 1

Key Prognostic Factors

The following features predict worse outcomes and mandate aggressive intervention:

• Hemodynamic instability (hypotension, cardiogenic shock) 1
• Anterograde coronary ischemia with compromised TIMI flow 1
• Extensive dissection extending into the aortic root (Dunning classification grade III) 2, 1
• Left main coronary artery involvement 3

Management Algorithm Based on Clinical Presentation

Hemodynamically Unstable Patients or Compromised Coronary Flow

Immediate bail-out stenting to seal the dissection flap and restore coronary perfusion is the primary strategy, as failure of percutaneous intervention is directly associated with mortality. 4, 1

• Deploy stents to cover the entire dissection entry point and seal the intimal flap 4, 1
• Careful wiring of the true lumen is essential to prevent extension 4
• If percutaneous intervention fails or is technically impossible, emergency coronary artery bypass grafting (CABG) must be performed immediately 1, 5
• A multidisciplinary "shock team" approach coordinating interventional cardiology and cardiac surgery is required 1

Hemodynamically Stable Patients with Preserved Coronary Flow

Conservative medical management is reasonable for distal dissections or when coronary flow remains preserved (TIMI 2-3), particularly if the dissection is small and does not involve the left main. 2, 5

• This approach requires continuous hemodynamic monitoring and readiness for immediate intervention if clinical deterioration occurs 5
• Serial imaging with computed tomography angiography guides ongoing management decisions 4

Aortocoronary Dissection with Aortic Extension

When dissection extends retrograde into the aorta, classification determines management:

• Type 1 (intimal tear) and Type 2 (intramural hematoma): Conservative medical therapy with close surveillance is reasonable if coronary flow is preserved 2
• Type 3 (pseudoaneurysm) and Type 4 (rupture): Require immediate surgical or endovascular repair 2
• If coronary involvement is present, stent implantation sealing the flap may be attempted first 2

Specific Anatomic Considerations

Left Main Dissection

• Incidence is approximately 0.07% of all catheterization procedures, twice as common during PCI versus diagnostic angiography 3
• 82% of patients require revascularization (stenting or CABG), with only 16% managed conservatively 3
• In-hospital outcomes are favorable when recognized promptly and managed appropriately, regardless of revascularization strategy 3
• Five-year MACE rates approach 39% among revascularized patients, emphasizing the need for long-term surveillance 3

CTO Procedures

• A significant proportion of iatrogenic dissections occur during chronic total occlusion (CTO) interventions due to vessel complexity and calcification 1
• Heightened vigilance and lower threshold for intervention are warranted in this setting 1

Medical Management Principles

Hemodynamic Targets

• Target systolic blood pressure 100-120 mmHg to maintain coronary perfusion while minimizing aortic wall stress 6, 7
• Target heart rate ≤60 bpm with intravenous beta-blockers to reduce shear stress 6, 7
• Initiate beta-blockade before vasodilators to prevent reflex tachycardia that can propagate dissection 6, 7

Absolute Contraindications

• Never use intra-aortic balloon counterpulsation in the setting of aortic dissection or severe aortic regurgitation, as it augments aortic diastolic pressure and worsens outcomes 6, 8
• Avoid inotropic agents that increase contractile force and aortic wall shear stress 6, 8

Surveillance and Follow-Up

• Obtain computed tomography aortography after stabilization to assess residual aortic dissection extent 4
• For patients with aortic extension, follow-up imaging at 6 months, 12 months, then yearly if stable 8
• MRI is preferred for serial surveillance to avoid radiation and nephrotoxic contrast 8

Critical Pitfalls to Avoid

• Do not delay intervention in hemodynamically unstable patients or those with compromised coronary flow—mortality risk is time-dependent 1
• Do not attempt conservative management when anterograde ischemia is present, as this predicts poor outcomes 1, 5
• Ensure true lumen wiring during bail-out stenting to prevent dissection extension 4
• Avoid vasodilators without prior beta-blockade, as reflex tachycardia increases aortic wall stress 7, 8
• Recognize that failure of percutaneous intervention mandates immediate surgical consultation—delays in CABG after failed PCI are associated with mortality 1