Timing is Everything: Emergency CABG for Guide Catheter-Related Left Main Coronary Artery Dissection With a Porcelain Aorta
Joseph M. Arcidi, Jr.1, Wendolyn A. Cox2, Swapna S. Mamidipally2, John L. Joliff2.
1Michigan Center for Heart Valve Surgery/University of Kansas Health System St. Francis Campus, Grand Blanc, MI, USA, 2University of Kansas Health System St. Francis Campus, Topeka, KS, USA.
OBJECTIVE: Although emergency stenting has been proposed as the initial strategy for iatrogenic left main coronary dissection (LMCAD), we present a collaborative CABG success with LMCAD and a porcelain ascending aorta.
METHODS: The limited history from emergent consultation was that this 78yo woman with preserved LVEF presented with a small non-STEMI. Following uneventful mid-RCA DES insertion, proximal circumflex DES deployment had been complicated by LMCAD from a 6Fr nylon/wire braid-reinforced guide catheter. There was hyperacute anterolateral ST-segment elevation, no circumflex flow, and guidewire-supported LAD perfusion (Figure 1A). Initial catheterization images suggested aortic root calcification (Figure 1B). We requested immediate IABP insertion, and upon expedited OR transfer, the arterial waveform showed only augmented diastole. Prompt sternotomy revealed nonclampable, porcelain aortic calcification with one soft spot for cannulation and one for proximal(s). Cardiopulmonary bypass commenced, but endovein harvest yielded unusable conduit, and saphenous vein proximal-seal devices (SVPD) and coronary stabilizers needed to be retrieved from a neighboring hospital. The SVPD arrived first, just as both skeletonized LIMA and open, single-vein harvests were completed, and one SV proximal was performed. After stabilizers arrived and following guidewire removal, the full-length LIMA was attached beyond an intramyocardial LAD. ST-segments normalized after distal SV anastomosis to a posterolateral circumflex artery.
RESULTS: Only modest catecholamine support was needed. After POD 1 extubation, we learned of the patient's oxygen-dependent COPD. The LVEF before POD 9 discharge to rehab was 55%.
CONCLUSIONS: Our success in this novel combined scenario supports a continued role for coordinated, immediate CABG in iatrogenic LMCAD.
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