Left Main Trunk Coronary Artery Dissection as a Consequence of Inaccurate Coronary Computed Tomographic Angiography

 

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18 Comments

  1. The following case is of my father. He had mild high cholesterol. Echo showed atherosclerosis of carotid. Holter showed ST-segment depression with HR > 90. He had a Dual source computed tomography (DSCT) to show severe coronary disease. But he has no symptom at all and takes all medication in guideline and refuses to have PCI. His cholesterol is normal now and without symptom.

    1. Liu, Qianqian wrote:
    Dear colleagues,
    My father just had a Dual source computed tomography (DSCT) that showed severe coronary disease. He has no symptoms at all, and takes all medicine in suggested by guidelines, but refuses to have PCI. I wish to transmit this to you, for discussion. Do you have any suggestions? Thank you.
    Liu, Qianqian MD
    Cardiovascular Department
    Peking University Shenzhen Hospital
    518036, P.R. China.

    2. Steven E. Nissen wrote:
    CT angiography is not a reliable method for detection of coronary disease. We do not recommend angiography or PCI for asymptomatic patients and we never do CTA in such patients. I would suggest a nuclear perfusion study. If negative, continue preventive measures.
    Steve
    Steven E. Nissen MD MACC
    Chairman, Department of Cardiovascular Medicine
    Cleveland Clinic Foundation
    9500 Euclid Ave.
    Cleveland, Ohio 44195

    3. Paul Schoenhagen wrote:
    Dear Qianqian,
    I have reviewed the images quite well. The only step I can not do without the CD is to load the dicom files into the advanced workstation for 3-D reconstruction.
    However, I think this would not change the conclusion. CT is very good if there is no disease (high negative predictive value). However if there are calcified lesions, CT is not very good in predicting the precise severity of stenosis. Therefore, for your father, you could say that there is calcified disease in all 3 vessels (but not the left main) and that there is a relatively high probability that some of these lesions have significant stenosis.
    You then have to make a CLINICAL decision how to proceed in particular because he has no symptoms. If necessary a stress test may be the next step?
    Paul

    4. 刘健
    做心肌双核素,阳性,做造影。药物治疗不是不行,但是,如果缺血,存在心梗的可能。
    刘健
    Translation: Nuclear perfusion imaging , positive, do angiography.
    Drug treatment is not bad, but if there is ischemia, there is the possibility of myocardial infarction.
    Liu, Jian

    5. Two other colleagues suggested coronary angiography; another colleague suggested forgetting coronary angiography.

    6. My mother had PCI, and suggested not to have PCI anymore which didn’t make her feel better.

  2. Many years ago, as a student, I did a clinical rotation in the Department of Gastroenterology at Haddassah Hospital in Jerusalem. There, while rounding with Dr. Wengrower (it is crazy that I even remember his name) he told me and my co-students the following pearl:

    “No indication — COMPLICATION!”

    Every day I see what he meant. Studies that are ordered as fishing expeditions that show findings of unknown clinical significance that result in the patient undergoing more tests, maybe some unnecessary treatments, and definitely a lot of anxiety.

    It is imperative that ordering physicians have a clear grasp of what questions they need answered and what is the best test to get that answer.

    Having said that: Isn’t a 52-year-old-woman with atypical chest pain a great candidate for a CTA? The doctors took advantage of the great negative predictive value of CTA in a low problem patient. The problem was what to do with the presence of some scattered plaque. They did not know what to do with that.

    Are we imagers at fault for not educating our clinical colleagues more?

  3. It is true that we should all “treat the patient, not the monitor”, and the case presented and the poor outcome is indeed unfortunate and tragic in nature.
    However, we should all be careful with conclusions.
    In fact, left main dissection is a known (and rare) complication of invasive coronary angiography, not of coronary CT angiography.
    Non-invasive coronary CT angiography, in most cases, allows the exclusion of obstructive CAD and therefore avoiding unnecessary invasive angiograms (not really rare in our days…).
    The recently published appropriateness criteria for the use of cardiac CT are helpful in setting the “frame for use”.
    Overall, when used appropriately, coronary CT angiography is a useful and robust diagnostic tool in symptomatic patients with chest pain.

  4. Replies from Chinese doctors:

    1. Bluepunk: 心衰也不是冠脉CT造成的呀:
    Translation: Heart failure was not caused by coronary CT angiography.

    2. Sunxuwcj: 结果造影时导致左主干剥离吧?不是因为做CT而导致的吧??为什么后面又说不好给低危患者随便作CT呢?现在很多患者没症状也做冠脉CT来体检呢:
    Translation: Coronary angiography caused dissection of the left main coronary artery, not CT. Why not to use cardiac computed tomography angiography in low-risk patients? There are many patients without symptoms asking for CT now.

    3. Ninenine: 嗯,感觉这篇文献说的不是很明白,不过感觉确实有时候CTA检查还是要注意有指征再做:
    Translation:We should use CT with indication.

    4. Crazyandy : 觉得这篇文章写得很好,不知道会不会给那些重影像而轻临床的医生一些启发。最近,美国心脏协会(AHA)及多家相关学会联合发布了心脏冠状动脉CT血管造影(CTA)专家共识。对CTA的临床应用进行规范。不知道大家对冠脉CTA的应用现状有何看法,大家都来谈一谈
    Translation: Good paper! I suggest to study guidelines of AHA for CTA.

  5. 5. Malibin1975: 还是不理解这个冠状动脉主干夹层和CTA有什么关系?CTA是对比剂静脉入血,动脉显影,对动脉没有压力性损伤,也不可能造成动脉的夹层或夹层加重。恰恰很好显示了冠状动脉壁的钙化,给心内医生做导管的时候一个提醒,粗暴的插管和过大的球囊压力会造成内膜和外膜的撕裂损伤的概率增高。而心内医生估计没有意识到这点,而造成了上述并发症的发生。所以这个病例的前因后果和CTA没有一点关系:
    Translation: : Dissection of the left main coronary artery has nothing to do with CT. Interventional cardiologists should improve their technique.
    I do not understand what is the relation between main coronary artery dissection and CTA ? CTA is a contrast agent into the blood vein for artery imaging. There is no pressure on the arterial which may lead injury and can not result in arterial dissection. It is just a good show for calcification of coronary artery wall which
    reminds the interventional cardiologist that violent balloon catheter injection and excessive pressure will increase the probability of the tearing and damage on intima and adventitia. The interventional cardiologist did not realize it and cause the complications above . Therefore, dissection of the left main coronary artery has nothing to do with CT.

  6. 请读一下附件的全文, CTA 显示病变较重才做造影, 结果造影显示病变没有那么重,没必要做造影, 但造影的并发症是致死的:
    Translation: This paper shows that the result of CTA is not accurate and more severe , thus leads to the lethal coronary angiograghy which is not necessary.

  7. 1. Ataiever:不是CTA不好,而是没有正确解读CTA的结果。如果这个夹层也要怪罪CTA,那是不是可以继续推广——不典型胸痛看医生而导致夹层?
    Translation: It’s not that CTA isn’t good, but it isn’t the right solution for the needed results. If we blame CTA for this dissection , that can continue to promote — atypical chest pain to see doctor and lead dissection?

    2. Black-Stone: CT显示病变并不严重啊,只是钙化和非钙化斑块而已.因为CT所见的冠脉斑块形成就做造影,这个适应症把握的有问题。所以这个病例的问题出在对冠脉造影这种有创性检查指征掌握不严格,与冠脉CT无关,而且对这个患者而言,冠脉CT检查也不算过分。这篇文章的作者有点莫名其妙。
    Translation: CT shows that lesions are not serious, but just non-calcified plaques and calcification . This invasive indication was not strict just with the coronary plaques from CT. So the problem of this case is on coronary angiography , not on coronary CT . The coronary CT check is not too much for this patient. This author of article is a bit strange.

    3. Yiyisue: 感觉对于这样的病人,如果没有禁忌症,可以考虑做核素心肌显像来评价是否有心肌缺血改变。
    Translation: Nuclear myocardial perfusion imaging may be suitable to assess myocardial ischemia for this patient if without contraindication .

  8. 4. Malibin1975:的确有过度评价狭窄的可能性,但是问题是夹层的发生和CTA是没有一点关系。夹层的发生根本原因就导管活着导丝粗暴插入导致内膜撕裂,造成假腔扩大,真腔闭塞从而加重心肌缺血。不过容易发生夹层的患者,血管内膜情况也不会好,心导管治疗的必要性是存在的,问题就是你怎么做好的问题。我认为作者避讳了操作失当的问题,而把CTA过度评估归咎于事发的主因,这个问题还是值得斟酌的。

    Translation: CTA does have the possibility of over-estimation of stenosis, but the problem is that the occurrence of dissection has no relation with CTA . The catheter insertion causes dissection, resulting in expansion of false lumen, thereby true lumen occlusion and myocardial ischemia. However, intimal situation is not good in patients prone to dissection, there is need for cardiac catheterization . The question is how to treat the problem. I think that the authors discuss little about the malpractice problem, and blame the CTA assessment for the incident. The main cause of this problem is questionable.

  9. This note from HeartWire is wrong. It states from the Appropriateness criteria paper that: CCTA is “inappropriate” for detection of CAD patients with a low risk of heart disease, ability to exercise, non-acute symptoms that may be an “ischemic equivalent,” and an interpretable ECG.

    The patient did not have stable chronic angina. She presented with new onset of chest pain. Was it acute urgent? They don’t specify, but I don’t think so.

    Also, according to this Criteria, in a patient with a Non-acute Symptoms Possibly Representing an Ischemic Equivalent, the AUS are 5 (uncertain) for those at low risk, and 7 (appropriate) or those at intermediate risk. So this article from HeartWire is presenting the data completely wrong. They assign a score as INAPPROPRIATE to patients with a HIGH pre-test probability of CAD. Which is NOT the case here!

    In my mind, it was not a bad indication for CT. The ordering physician was at a loss when the results came back. Granted, the results were not the desired ones – and that has happened before and will happen some times. But if you take 100 cases with histories similar to hers, how many times will we get those results instead of no plaque or minimal plaque?

    If the Dr. thought the plaque was concerning, he should have done a nuclear stress test, not jumped to cath.

  10. I have to say the first line of this publication is irresponsible and negligent–CCTA in patients with a low pretest risk of coronary disease wastes resources and can even lead to horrendous outcomes…this is an evidence-based medical forum not a sensationalized tabloid.

    In my opinion, CCTA was the correct diagnostic tool when considering the patients background: age (52), gender (female), weight (obese), previously diagnosed with hypertension, and presenting with acute atypical chest pain. How often do we read, hear, and even see patients who fit this description have AMI’s in the ER or on the way to it. Also, how many have been prevented because of the quick diagnostic ability of CT.

    I agree with Dr. Kirsch, a perfusion test should have been used to rule out any ambiguity; instead the physicians (again in my opinion) were overzealous and created a snowball effect. But to publish this as if it’s the norm caused by overutilization and risk stratification is misinterpreting the chain of events.

  11. Diangose Heart Diseases from Face

    I am now studying Chinese medicine to treat heart diseases. The first step I’m studying is to read heart disease by face (facial recognition), based on the theory of Yellow Emperor-a classic medical book which was published 2,500 years ago. I have been trying this on my patients, and it seems very accurate.

    To further improve my practice, I find photos of faces online to test myself. The following are some photos of Mr. Bush. I think he has obvious heart disease from those photos, and suggest him for further prevention or treatment. However, I obviously do not have case documents of Mr. Bush to verify. Do you have any information about it? Or send other photos of faces for me to practice. Thank you!

  12. It is difficult to recommend any specific intervention of further testing without looking at the images first, but what would be the utility of perfusion testing in this situation? If the CT scan identified an obstructive plaque in a patient presenting with unstable angina, the appropriate next step is cardiac catheterization. If the plaque is non-obstructive, and the symptoms are then due to non-cardiac chest pain, no further testing is required and patient should get appropriate medical therapy for non-obstructive CAD with risk factor modification. An MPI study would only be useful, if the CTA was truly non-diagnostic. In an obese female, a SPECT study probably has a higher risk of non-diagnostic than a CT scan. So if there was some ambiguity, proceeding to cardiac catheterization is not unreasonable. Again, it’s difficult to judge without knowing all the circumstances of the case, but I would not jump to conclusions here. I do not see any obvious malpractice here.

  13. Coronary angiography complicated by dissection of the left main coronary artery is not malpractice in USA ?

    Ismail Dogu Kilic, Halil Tanriverdi, Harun Evrengul, Sukru Gur.
    Cardiology Research and PracticeVolume 2010 (2010), Article ID 794026, 3 pages.

  14. I agree with you, Dr. Royzman.
    The next step after the CT could have (and in hind sight should have) been health care management. Instead a decision was made between the physician and the patient (who happened to also be a nurse), which resulted in “a series of misfortunate events!” But I never meant to imply negligence or malpractice. I don’t think it was irresponsible on the part of the dr. to have referred the cath; in my opinion, it was more aggressive in that it’s a more invasive procedure (but a VERY safe one).

  15. The patient in question was a woman with a low pre-test likelihood of disease to start (1% estimated 10-year global cardiovascular risk by Reynolds; < 10% 10-year risk by Framingham) and presented with atypical chest pain. Paraphrasing the ACC appropriateness criteria document, "to send a patient for coronary CTA the downstream result of such task should be to obtain incremental information which combined with clinical judgment exceeds the expected negative consequences by a sufficiently wide margin for a specific indication that the procedure is generally considered acceptable care and a reasonable approach." Based on the ACC document, the use of coronary CTA for the indication of evaluation of acute chest pain in a patient with low pre-test likelihood of disease with normal EKG and negative cardiac biomarkers is uncertain (U5). Therefore, the use of coronary CT in this case would be acceptable to rule out disease since a negative study would rest the discussion based on both the high sensitivity and high negative predictive value of the test. However, a positive test wouldn't determine the presence of disease since the test has both a low specificity and a low positive predictive value. The issue of which test, or if any test should have been initially indicated in that patient would depend according to other compelling reasons (patient reassurance, initiation of exercise program etc.). Sending this patient to undergo coronary CTA was acceptable. The interpretation of the test results and use of the obtained information by the referred physician was poor. Indicating subsequent coronary angiography was wrong! The next step should have been either to perform a nuclear stress test (or stress PET if you consider the patient obese and not ideal for SPECT) or simply continue with risk factor modification without pursuing further expensive testing.

  16. Also see:
    Diagnostic Tests: Another Frontier for Less Is More: Or Why Talking to Your Patient Is a Safe and Effective Method of Reassurance.
    Redberg R, Katz M, Grady D.
    Arch Intern Med. 2010 Dec 13.
    PMID:

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