Catheterization and Cardiovascular Diagnosis 38:266 (1996)

Editorial Comment

Dissection After Coronary Stenting: Stretching the Limit?

Lowell F. Satler, MD, and Gary S. Mintz, MD Washington Cardiology Center, Washington, DC 2001 0

Although the greatest recent advance in the percutaneous treat- ment of coronary artery disease has been the introduction of the coronary stent, it too has its own limitations [ I ] . In this issue, Esente and associates describe a complication of coronary stent- ing: the development of a dissection after stent delivery. In this case report, the dissection was caused by the rupture of a high- pressure balloon resulting in disruption of the entire right coronary artery back to the ostium. The authors cleverly removed the en- trapped balloon and managed to repair the dissection by the careful placement of multiple overlapping stents in the proximal seg- ments.

Although the dissection in this case report was attributable to the rupture of a high-pressure balloon, dissection most frequently oc- curs due to local mechanical trauma at the stent margin creating a hematoma in the wall of the vessel. Management of this compli- cation is best approached by assessing the extent of the dissection (Fig. 1). Dissections can be categorized broadly into (1) minor- usually involving a very focal segment less than 5 mm from the stent margin, and (2) major-extending greater than 5 rn with prominent adventitid staining and, potentially, lumen compro- mise. The difference between these two is important to distin- guish. Minor dissections may be treated by prolonged low-pres- sure inflations at the stent margins. If this is unsuccessful or the dissection is major, the operator needs to be able to quickly deploy multiple additional stents to completely cover the disrupted seg- ment. Failure to do so is often associated with a high incidence of subacute closure. After the deployment of additional stents to cover the dissection, the treated site should be carefully inspected. If there is complete coverage of the dissection, no further inter- vention is required. In the presence of incomplete coverage, which happens when the operator cannot deliver additional stents due to technical reasons, an important decision must be made regarding the need to consider bypass surgery. Alternatively, platelet inhib- itors may be important pharmacology in the management of these incompletely covered dissections in avoiding subacute closure. It

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Resolutlm I canpi- I Fig. 1. Management of coronary stent dissections. ‘..5 mm length, haziness or limited staining; ** -5 mm length, deep staining.

is hoped that the introduction of scratch-resistant high-pressure balloons designed specifically for stenting and the development of lower-profile, more easily deliverable stents will be able to avoid and/or treat the problem of “stretching the limit” more easily.

REFERENCES 1. Shaknovich A: Complications of coronary stenting. Coronary Artery

Dis 5583-589. 1994.

0 1996 Wiley-Liss, Inc.