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CLINICAL STUDIES

Short- and long-term evolution of unstented nonocclusive coronary dissection after coronary angioplasty

Alberto Cappelletti, MD^a, Alberto Margonato, MD, FESC^a, Giuseppe Rosano, MD, FACC^a, Alessandra Mailhac, MD^a, Fabrizio Veglia, MD^*, Antonio Colombo, MD, FACC and Sergio Lorenzo Chierchia, MD, FESC, FACC^a

^a Division of Cardiology, Istituto Scientifico H San Raffaele, Milan, Italy
^* Unit of Biostatistics, Istituto Scientifico H San Raffaele, Milan, Italy
Unit of Interventional Cardiology, Istituto Scientifico H San Raffaele, Milan, Italy

Manuscript received October 29, 1998; revised manuscript received June 17, 1999, accepted July 19, 1999.

Reprint requests and correspondence: Dr. Alberto Cappelletti, Division of Cardiology, Istituto Scientifico H San Raffaele, Via Olgettina 60, 20132 Milan, Italy

OBJECTIVES

We assessed the short- and long-term clinical and angiographic outcome of nonocclusive unstented dissection after percutaneous transluminal coronary angioplasty (PTCA) and its correlation with restenosis.

BACKGROUND

The use of stents has dramatically increased both the number and the cost of coronary revascularization procedures. However, this technique is not completely risk free, and its benefits have not been fully demonstrated in uncomplicated dissections.

METHODS

We studied 129 consecutive patients with 49 nonocclusive dissections after PTCA (grades A to D of National Heart, Lung, and Blood Institute classification) and good distal flow (TIMI [Thrombolysis in Myocardial Infarction] flow grade 3). All patients underwent coronary angiography at 24 h and at six months post-PTCA. Clinical status was assessed every three months in the outpatient clinic. Study subjects were matched with 60 other patients in whom stenting was performed for the presence of dissection.

RESULTS

In the former group, all but two patients (with type E dissection, which evolved to coronary occlusion and myocardial infarction) improved their dissection score during follow-up: at six months only 18 dissections were still angiographically visible, and no clinical adverse events were recorded. In the dissected vessels, the restenosis rate was significantly lower than in those without dissection (12% vs. 44%, p < 0.001); in the stented vessels, the restenosis rate was 25% (15/60).

CONCLUSIONS

In the presence of TIMI flow grade 3, coronary dissection is associated with a favorable outcome and predicts a low restenosis rate. These results caution against the indiscriminate use of intravascular prostheses in the event of nonocclusive coronary dissection.

Abbreviations and Acronyms   CK-MB = creatine kinase–myocardial band   ECG = electrocardiogram, electrocardiographic   NHLBI = National Heart, Lung, and Blood Institute   PTCA = percutaneous transluminal coronary angioplasty   QCA = quantitative coronary angiography   TIMI = Thrombolysis in Myocardial Infarction

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