In an emergency. UPLM stenting ok. But electively with 2VD CABG still first option

Dear Jose, I am convinced that in case of LM dissection due to manipulation of diagnostic catheters your first option should be PCI, for the following reasons:

-a dissection of the left main could bring to acute occlusion of the vessel, thus even if you have an available surgery at your center, you cannot face the risk to wait for 1-2 hours (or more) without adequate antiplatelet treatment;

-a CABG intervention in an emergency setting is different from an elective intervention, and veins instead of arteries are often used as conduits;

-the dissection derived by manipulation of diagnostic catheters is usually of the proximal edge of the left main. PCI in this setting has excellent results at follow up, and is usually an easy intervention.

Thus, I am convinced you have done the right thing! I only suggest you to do a control angio after 6-9 months.

Dear Bernardo

I agree with you. I really think that the best option is to immediately fix the problem performing an ULM PCI.

In USA this is still not frequently done and the rate of mortality is very high (about 30%) when the patient is referred to surgery.

In an urgent setting, without a well stratified risk for cardiac surgery, I think is better to solve, quickly, the emergent problem and afterward think of what to do next....

Dear Bernardo. I agree with the reasons that you wrote to explain your choice.

Definitly depend of clinical situation. The first step - emergency PCI ( relativ contraidication to CABG - DAPT )

First of all you should try to understand why the dissection occured to learn from this case. DES Stenting for bail out is quite reasonable.

I think that if you can put the stent just do it! You do not really have too many options because LM dissection is a critical complication.

Dear Dr. Vorpahl.After 38 years in cath lab I learned that coronary dissection occur in very skill hands and all cardiology intervencionist. But every case can be some knowledge.

Dr Jacob - you are right, it can occur in experienced hands as well. In case of repetitive cases, you should rethink at your strategy (eg type of diagnostic catheters used, manipulation, ...).

I rather wanted to emphasize to keep spontaneous dissections in connective tissue diseases in mind.

I think it is a complex problem...So many factors should be considered such as susceptiability genetics backgrounds and clinical risk factors. Up to now, no consistent clinical decision making clarify the issue. Since clinical decision making studies should be conduct to handle it... The best expectation is a sophistacated mathematical model can handle it...Clinicians can make the best desicion based on models...

I absolutely agree. There is no sense to transfer the patient on emergency to the Cardiac surgery Unit if you can "easily" manage the problem, but anyway could be realistic to alert surgeons on duty.

But, if the patiens suffers also "peripheral" stenoses, why don't threat on emergency left main dissection and refer to cardiac surgery to threat him later and definitely by means of complete arterial revascularization on elective basis? As you know, in a patient as young as yours, the risk of further revascularization is very high.

Dear Castorino. I agree with you if there is experience with use of both Internal Thoracic Arteries. In surgical revascularization if venous graft is performed there is a high risk of other revascularization. Although many surgeons talking about the use of both Thoracic Internal Artery, most of them performed only one Thoracic Internal anastomosis.

Dear Jose

In general there is no right and wrong in the way to intervene in this situation, both options are valid and each case should be discussed with the cardiac team and decide what is the best opiton for each patients, I operated on patients with acute dissection and our cardiology colleagues do them as well and both ways have good results.

I agree with Koudieh. But, what is your opinion about spontaneous dissection?

I think that your option in spontaneous dissection due to catheter manipulation is to remain calm, try to stent the proximal LM and then regularly follow up the patient. It is really difficult for surgeons to handle this kind of complications but they should be informed and at your disposal if dissection deteriorates and PCI is not feasible.

I refer to primary spontaneous coronary dissection, no related to angiography, surgery or trauma...

In this setting I agree with Bernardo; go with a bailout stent in the interest of time and because it is immediately available. Waiting any length of time with so much myocardium at risk is not advisable. There are plenty of case reports in the literature but I could only find one decent case series that compared PCI with CABG and showed no difference in 5 yr MACE outcomes. My choice would also be to go with LM stenting. Here is the reference; take a look at Table 3 and 4.

Iatrogenic left main coronary artery dissection: incidence, classification, management, and long-term follow-up.

Eshtehardi P, Adorjan P, Togni M, Tevaearai H, Vogel R, Seiler C, Meier B, Windecker S, Carrel T, Wenaweser P, Cook S.

Am Heart J. 2010 Jun;159(6):1147-53. doi: 10.1016/j.ahj.2010.03.012.

Dear Zahid, I agree with you. Thank you for the information about the article.

Dear Ines Monte. Spontaneous coronary dissection is not frequent and the clinical features depend of the extension of dissection. I prefer immediate stent implantation to solve the problem. One or more stents.

I agree with LMCA stunting,by the way what would be your recommendation for DAP duration .Will it be for life long just because its in the LMCA? your thoughts please

Dear colleague,

we have experince with left main dissection. Stent in left main trunk is bringing a risk for further aortic dissection, if it is a basically artery wall disease. At same time onother our patient had a good prognosis after 30 days following and ,,waiting and waching,, on cardiac surgery with LMCA dissection and good distal flow. Recovery was spontaneous.

My comments refered to spontaneous artery coronary dissection. Jatrogens CADissection approach is different (stent is preferable)

It depends on whether the patient is stable or not. In an unstable situation with occlusion of the the left main you have to do something directly and this is may be stenting. In a stable situation it may be better to discuss the strategy together with a surgeon. It furthermore depends on the anatomy of the dissection. If the dissection is propagating in an antegrad manner it is probably the best to fix it with a stent directly. In case of retrograde dissection, in the worst case scenario in the ascendent aorta, it may be indicated to perform imaging first (CT scan, TEE). In this case to go on injecting contrast medium in the left main may even worsen the situation.

I think even in retrogade dissection, the stent implantation is better than wait the surgical treatment. Rarely there is aortic propagation of the dissection.

i think that a stent implentation is better because is it faster.

we had to manage such complication 10 days later dealing with ostial dissection with total occlusion of the left circumflex and extension to the LAD.

we implanted a stent from left main to LAD and then a second wire easely reached the lef circmflex, we performed a kissin bammon with a very good result

Doctor Elhadj. I agree with you, and did you make a good job in the case described.

yes with total recovary of the Lcx

Dear JOSE

I think it depend on somethinngs

1-patient stability

2-type and location of dissection

3-involvement of bifurcation

4-anatomy of LAD &LCX involvement

in unstable patient LM stenting is the best choice

in stable patient that you can perform good revasculariztion stenting is acceptable

but in stable patient with bifurcation involvement and both artery lesion surgry is better.