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Dissection of the left main coronary artery after blunt thoracic trauma: Case report and literature review.
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PMID:  20649988     Owner:  NLM     Status:  PubMed-not-MEDLINE    
Abstract/OtherAbstract:
Blunt chest trauma is commonly encountered by surgeons and is rarely associated with cardiac injuries. The incidence of cardiac injury is rare but can be rapidly fatal, requiring prompt recognition and treatment. We review the case of a 37 year-old male who was involved in a head-on motor vehicle collision at highway speed and was found to have an isolated left main coronary artery dissection. We then review the supporting literature for evaluation of blunt cardiac injuries and the treatment options for traumatic coronary dissection.
Authors:
Mollie M James; Marnix Verhofste; Cass Franklin; Greg Beilman; Charles Goldman
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Publication Detail:
Type:  Journal Article     Date:  2010-07-22
Journal Detail:
Title:  World journal of emergency surgery : WJES     Volume:  5     ISSN:  1749-7922     ISO Abbreviation:  World J Emerg Surg     Publication Date:  2010  
Date Detail:
Created Date:  2010-08-04     Completed Date:  2011-07-14     Revised Date:  2011-09-02    
Medline Journal Info:
Nlm Unique ID:  101266603     Medline TA:  World J Emerg Surg     Country:  England    
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Languages:  eng     Pagination:  21     Citation Subset:  -    
Affiliation:
University of Minnesota, Department of Critical Care and Acute Care Surgery, Minneapolis, MN, USA. molsjames@msn.com.
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Full Text
Journal Information
Journal ID (nlm-ta): World J Emerg Surg
ISSN: 1749-7922
Publisher: BioMed Central
Article Information
Copyright ©2010 James et al; licensee BioMed Central Ltd.
open-access:
Received Day: 17 Month: 3 Year: 2010
Accepted Day: 22 Month: 7 Year: 2010
collection publication date: Year: 2010
Electronic publication date: Day: 22 Month: 7 Year: 2010
Volume: 5First Page: 21 Last Page: 21
Publisher Id: 1749-7922-5-21
PubMed Id: 20649988
DOI: 10.1186/1749-7922-5-21

Dissection of the left main coronary artery after blunt thoracic trauma: Case report and literature review
Mollie M James1 Email: molsjames@msn.com
Marnix Verhofste2 Email: artvessel@aol.com
Cass Franklin3 Email: transdod2@aol.com
Greg Beilman1 Email: beilm001@umn.edu
Charles Goldman3 Email: cgoldman@mercydesmoines.org
1University of Minnesota, Department of Critical Care and Acute Care Surgery, Minneapolis, MN, USA
2Iowa Heart Center, Cardiothoracic Surgery Division, Des Moines, IA, USA
3Mercy Medical Center, Department of Trauma Services, Des Moines, IA, USA

Background

Blunt chest trauma is commonly encountered by trauma surgeons and has a variable clinical course. The spectrum of cardiac injuries ranges from mild cardiac contusion to cardiac failure or death. The diagnosis of blunt cardiac injury (BCI) can be challenging because chemical markers, nuclear studies and echocardiogram rarely correlate with the severity of injury. This article reviews a case of coronary artery dissection leading to acute ischemia, the diagnostic recommendations for evaluating patients at risk for BCI, and the therapeutic options for traumatic coronary artery dissection.


Case Report

A 37 year-old white male presented as a trauma patient after a head-on motor vehicle collision at highway speed. The patient was the restrained driver; the driver of the other car was fatally injured at the scene. Primary survey revealed an intact airway. The patient was talking without stridor; breath sounds were equal bilaterally. Pulses were palpable in all extremities and there was no evidence of jugular venous distention. He was neurologically intact with a Glasgow Coma Score of 15. The patient complained of chest pressure and shortness of breath.

Initial vital signs were: systolic blood pressure 118 mmHg, pulse 99 beats per minute, respiratory rate 28 breaths per minute, and an oxygen saturation of 94% with supplemental oxygen at 2 liters per minute. He had a thoracic contusion consistent with a seatbelt sign and his sternum was tender to palpation. Physical findings also revealed a deformity of the left ankle. He had no history of medical problems or previous chest pain. Prior to the incident his only surgery was a knee arthroscopy. He had a 30 pack-year history of smoking and drank alcohol regularly.

The trauma evaluation was completed, including cervical spine, chest and pelvis radiographs, and a trauma laboratory panel (chest radiograph, Figure 1). An electrocardiogram (Figure 2) demonstrated acute ST elevation in leads I, aVL, aVF, and V2-V5. Based on the EKG findings suggesting ischemia, cardiac enzymes were ordered and, when noted to be elevated, the decision was made to proceed with a coronary angiogram. His cardiac enzymes were elevated with a creatinine phosphokinase of 454 ng/mL (38-120 ng/mL) creatinine phosphokinase-MB 13 ng/mL (< 3 ng/mL), and troponin of 0.02 ng/mL (< 0.04). He was given aspirin, intravenous morphine and metoprolol until his pain subsided. He underwent an emergent coronary angiogram (Figure 3) that demonstrated dissection of the left main coronary artery.

After the angiogram, the patient was taken urgently for a coronary artery bypass graft. At surgery he underwent a triple bypass graft as follows: reverse saphenous vein graft to obtuse marginal 1 (OM-1), reverse saphenous vein graft to ramus, and left internal mammary artery to left anterior descending artery. Postoperatively, he was admitted to the Surgical/Trauma Intensive Care Unit with an intra-aortic balloon pump (IABP) to augment cardiac function. He required re-exploration the first post-operative night for bleeding. A small uncontrolled side branch on the vein graft to the obtuse marginal artery was bleeding; it was repaired with a single 7-0 Prolene stitch.

After re-operation, the ejection fraction remained low at 15% per post-operative echocardiogram. He continued to require the IABP and vasopressors to sustain cardiac function. On the third post-operative day the IABP was removed; two days later vasopressor support was discontinued. Due to extensive injuries, he was not extubated until the twelfth day in the ICU. Concomitant injuries included left talus and calcaneus fractures that were surgically repaired during his hospital stay. He was discharged home on the 19th hospital day with an ejection fraction of 30-35%.


Discussion
Evaluation of suspected cardiac injuries

The Eastern Association for the Surgery of Trauma (EAST) has published a practice management guideline for patients with suspected BCI. A review of the literature supporting these recommendations can be found in table 1. Each patient with suspected cardiac injury should have an EKG upon arrival (Level I) [1]. Abnormal admission EKG should likely be followed with cardiac monitoring for 24 hours or until hemodynamically stable. Patients with normal EKG and no symptoms or other injuries can be discharged after a brief period of observation. This recommendation is supported by a review by Christiansen that showed over 80% of patients who developed a clinically significant arrhythmia had EKG changes on the initial study, suggesting that intake EKG can be considered a reasonably discriminating screening exam [2].

Echocardiography should be reserved for patients who are hypotensive either on admission or during the initial observation period. It can be helpful in diagnosing apical thrombi, pericardial effusion and tamponade. Echocardiograms added little clinical information for patients who were normotensive. Radionuclide imaging studies are too sensitive and lack specificity in the setting of trauma, so are not helpful in the evaluation of blunt cardiac trauma.

The EAST guidelines recommend against following cardiac enzymes because they are not helpful in predicting complications from BCI [1]. A review by Biffl, et al evaluated the management of suspected cardiac injury at a Level-One trauma center in Denver. Screening creatinine phosphokinase or troponin levels were frequently elevated post-injury and did not correlate with clinically significant BCI [3]. They identified clinical risk factors for complications in BCI including age greater than 55, an abnormal EKG at admission, the absence of chest pain, a widened mediastinum on imaging, a head injury with a Glasgow coma score less than 8, and pelvic fractures. In both univariate and multivariate analysis, these factors were more predictive of complications from BCI than cardiac enzymes [3].

Guidelines are helpful in directing the evaluation when thoracic injuries are suspected. The recommendations from EAST support a limited evaluation for negative screening tests and asymptomatic patients. If the initial screening evaluation is positive the algorithm is redirected to evaluate more specific injury patterns. In our case, there was evidence of malperfusion of the myocardial tissue in the anterior distribution, so we integrated cardiac enzymes and angiography to diagnose the potential causes of ST segment changes on the initial EKG. Efficiently proceeding from a screening evaluation to a diagnostic evaluation allowed for rapid detection and treatment of the coronary dissection.

Many types of cardiac injuries have been described after blunt chest trauma. Arrhythmia, cardiac contusion, and acute myocardial infarction are among the more common injuries [4]. Older patients can have ischemia induced by hemorrhagic shock superimposed on underlying cardiac disease, rather than from direct cardiac injury. Less commonly encountered are coronary artery laceration, thrombosis, or intimal dissection [4]. Clinically the injuries can by asymptomatic, or may cause angina, hemodynamic instability, or commotio cordis, resulting in sudden death.

Coronary Artery Dissection

Coronary artery dissections are most common in the left anterior descending artery (76%), right coronary artery (12%) and the circumflex (6%) [5]. Very few cases have been reported from blunt trauma such as waterskiing [4], contact sports such as basketball [6] and football [5], and high-speed impact such as motorcycle[7,8], or motor vehicle collisions [9-12]. Dissection of the left main coronary artery is among the most rare sequela of blunt chest trauma. One trauma-related left main coronary dissection was reported 3 days after a head-on motor vehicle collision at only 15 mph [13]. Cases that have been reported in the literature are listed in table 2.

Other causes of dissection unrelated to trauma include spontaneous lesions and iatrogenic injuries from coronary angiography. Spontaneous dissections have a 4:1 predilection for women with 25-33% occurring during pregnancy or the peripartum period [14]. Spontaneous lesions are associated with three conditions: 1) pre-existing coronary artery disease; 2) hormonal factors, such as pregnancy or oral contraceptive use, as stated above [14-16]; and 3) patients with tissue fragility disorders (e.g., Marfan's or Ehler-Danlos syndromes) [17]. Mortality with spontaneous dissection can be up to 70%, based on post-mortem studies after sudden cardiac death [17].

Iatrogenic injuries are rare, occurring in 3-6/10,000 angiograms. They are most commonly seen as RCA injuries, and can be due wire passage or balloon inflation [18].

Treatment of Coronary Artery Dissection

The approach to treatment of coronary artery lesions is variable and depends upon the mechanism, the co-morbidities of the patient, and degree of hemodynamic stability. Conservative management includes anticoagulation and observation if they are hemodynamically stable with minimal injuries. Thrombolytics can be administered to dissolve clot associated with an intimal injury, but are contraindicated in multiply injured patients. Revascularization can be achieved with percutaneous techniques or coronary bypass, and timing is dependent upon the clinical scenario.

Advancements in percutaneous interventions have prompted some to attempt revascularization using this method. Lesions in the LAD and RCA are highly amenable to stent placement [23]. Surgical revascularization is the preferred therapy in coronary lesions with the following characteristics: 1) unprotected isolated LMCA disease, 2) contraindication to anti-platelet therapy including aspirin, heparin, and clopidogrel, 3) history of known coagulopathy or bleeding diathesis, or 4) pregnant women [23]. The need for subsequent anti-platelet therapy following stent placement to assure patency limits the utility of these approaches in the multiply injured blunt trauma patient. Some of these patients are already coagulopathic and the addition of these agents can destabilize clots in solid organs leading to life-threatening hemorrhage, or propagate an intracerebral hemorrhage with grave clinical consequences.

In our patient the decision to proceed to coronary bypass was likely due to two factors. Most importantly, the dissection involved the left main coronary artery, which is preferentially treated surgically [23]. Secondly, our patient had a contraindication to percutaneous techniques because of his risk of bleeding. Our approach is supported by a number of successful cases already reported. Korach, Smayra, and Boland all report cases of motor vehicle collisions with resultant LAD coronary dissection that were successfully treated with surgical revascularization [9,10,13]. Harada had a similar success story, but the dissection was the left main coronary artery [8]. Redondo reported a mortality in the case of a 45 year-old female diagnosed with a left coronary artery dissection after a motor vehicle collision [11]. Attempts to treat with angioplasty and heparinization were complicated by fatal intra-abdominal hemorrhage.

Coronary dissection after blunt chest trauma has been successfully treated with a more conservative approach. Hobelmann reported the case of a 32 year-old male who suffered an RCA dissection after being elbowed in the chest during basketball [6]. The lesion was successfully treated with eptifibitide, heparin and stents. A focal right coronary artery lesion can be successfully stented, similar to the treatment of lesions in coronary artery disease [23]. Also, the risk of bleeding associated with the use of anticoagulation and anti-platelet agents was lower due to the isolated nature of the trauma. Hazeleger reported an LAD dissection 2 months after a tackle in football which was successfully treated with a stent [5]. Once again, left anterior descending artery lesions respond well to stent placement [23]. Also, the time interval from injury to diagnosis significantly reduces the risk of bleeding from anticoagulation necessary when stents are utilized.


Conclusions

Blunt thoracic injury is commonly encountered in a trauma center, and a small fraction of those patients will present with blunt cardiac injuries. The goal of evaluation should be identifying patients with clinically relevant complications related to the cardiac injury and providing the appropriate level of care to meet patients' needs. We present a review of the diagnostic tools for evaluating blunt cardiac injury.

Recommendations include obtaining an initial EKG on all patients at risk for injury. If the EKG is abnormal, cardiac monitoring may be reasonable for 24 to 48 hours or until the patient is asymptomatic and hemodynamically stable. Echocardiograms should be reserved for patients presenting with hemodynamic instability and can be helpful in identifying tamponade, pericardial contusion, or apical thrombi. Additional means of testing, such as serial enzyme monitoring, have additional costs with limited clinical benefit.

Coronary artery dissection is a rare clinical condition, with variable causes including trauma, iatrogenic lesions from angiography, and spontaneous dissections. Despite the etiology of the dissection, treatment is dependent upon the location of the lesion. Patients with LMCA lesions or those with a high-risk of bleeding will likely need to undergo coronary bypass. Lesions isolated to the LAD or RCA, and with isolated trauma, can be treated with percutaneous techniques.

In our patient sustained a high-risk blunt chest trauma from a motor vehicle collision. An EKG was ordered to evaluate his symptoms, and the screening test initiated a diagnostic evaluation. Based on those findings, additional diagnostic tests--the cardiac enzymes and angiogram--were justified and provided rapid diagnosis of the coronary artery dissection. Prompt recognition, evaluation and treatment resulted in immediate surgical revascularization and discharge to home on hospital day 19.


Competing interests

The authors declare that they have no competing interests.


Authors' contributions

MJ is the primary author and reviewed the case and the literature. MV, CF provided case review details and editorial input. GB provided direction for the paper and editorial commentary. CG was involved in writing and editing the paper.

All authors have read and approved the final manuscript.


References
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Christensen MA,Sutton KR,Myocardial ContusionAm J Crit CareYear: 1993228348353574
Biffl WL,Moore FA,Moore EE,Sauaia A,Read RA,Burch JM,Cardiac enzymes are irrelevant in the patient with suspected myocardial contusionAm J SurgYear: 199416865237 discussion 7-8.. 10.1016/S0002-9610(05)80115-17977989
Greenberg J,Salinger M,Weschler F,Edelman B,Williams R,Circumflex coronary artery dissection following waterskiingChestYear: 1998113411384010.1378/chest.113.4.11389554664
Hazeleger R,van der Wieken R,Slagboom T,Landsaat P,Coronary dissection and occlusion due to sports injuryCirculationYear: 200110381174511222484
Hobelmann AJCPEBHCase of the month: Right coronary artery dissection following sports-related blunt traumaEmerg Med JYear: 200623580310.1136/emj.2006.03459516794113
Leong D,Brown M,Blunt traumatic dissection of the proximal left anterior descending arteryEmerg Med JYear: 20062312e6710.1136/emj.2006.04142617130588
Harada H,Honma Y,Hachiro Y,Mawatari T,Abe T,Traumatic coronary artery dissectionAnn Thorac SurgYear: 2002741236710.1016/S0003-4975(01)03515-912118767
Korach A,Hunter CT,Lazar HL,Shemin RJ,Shapira OM,OPCAB for acute LAD dissection due to blunt chest traumaAnn Thorac SurgYear: 2006821312410.1016/j.athoracsur.2005.09.07016798238
Smayra T,Noun R,Tohme-Noun C,Left anterior descending coronary artery dissection after blunt chest trauma: assessment by multi-detector row computed tomographyJ Thorac Cardiovasc SurgYear: 20071333811210.1016/j.jtcvs.2006.11.02617320595
Redondo B,Gimeno JR,Pinar E,Valdes M,Unusual presentation of acute coronary syndrome. Bilateral coronary dissection after car accidentAm J Emerg MedYear: 20092781024e3510.1016/j.ajem.2008.12.038
Goyal G,Singh G,Kapoor R,Rare case of blunt chest trauma induced left main and LAD dissection in association with anomalous RCA originHeartYear: 20099514117810.1136/hrt.2009.16891419564430
Boland J,Limet R,Trotteur G,Legrand V,Kulbertus H,Left main coronary dissection after mild chest trauma. Favorable evolution with fibrinolytic and surgical therapiesChestYear: 1988931213410.1378/chest.93.1.2133257183
Rogers IS,Rinaldi MJ,Humphrey CB,Boden WE,Dougherty JE,Postpartum dissection of the left main coronary arteryClin CardiolYear: 2006294175810.1002/clc.496029041016649728
Cini R,Iezzi F,Sordini P,Pasceri V,Spontaneous left main coronary artery dissectionInteract Cardiovasc Thorac SurgYear: 200875943410.1510/icvts.2008.18234518614552
Vogiatzis I,Hadjimiltiades S,Sachpekidis V,Parcharidis G,Spontaneous coronary artery dissection and acute myocardial infarction during pregnancyHellenic J CardiolYear: 2010511748020118050
Nogueira de Macedo R,de Paula Miranda S,Vieira da Costa RL,Spontaneous coronary artery dissection - a diagnosis to be considered in young patients presenting with acute myocardial infarctionJ Invasive CardiolYear: 20092112E245719966376
Papadopoulos DP,Moyssakis I,Perakis A,Athanasiou A,Anagnostopoulou S,Benos I,Acute myocardial infarction due to spontaneous dissection of the right coronary artery in a young maleCardiovasc Intervent RadiolYear: 2004275536710.1007/s00270-004-0256-515383861
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Figures

[Figure ID: F1]
Figure 1 

The chest radiograph taken in the trauma bay does not demonstrate acute intrathoracic injury.



[Figure ID: F2]
Figure 2 

The EKG demonstrates ST segment elevation in leads I, III, aVL, and aVF, as well as precordial leads V2-V5. This suggests anterior wall ischemia and the patient underwent emergent coronary angiography.



[Figure ID: F3]
Figure 3 

The angiogram demonstrates a 50% diffuse stenosis of distal left main artery with left main dissection. The LAD had 95% occlusion and 50% stenosis of the circumflex arteries. An intra-aortic balloon pump was placed and the patient was taken emergently to the operating room for coronary bypass.



Tables
[TableWrap ID: T1] Table 1 

Review of Myocardial Contusion Evaluation in Blunt Thoracic Trauma


Author/Journal Number of patients Number of cardiac complications Conclusions
Baxter, et al. [19]
Retrospective 6 year review of all patients with blunt chest trauma
280 35 patients with myocardial contusion (MCC)
7 complications
2 deaths
* Complications of MCC manifest within 12 hours.
* Patients with suspected MCC should have cardiac monitor and enzyme monitoring for 24 hours or until hemodynamically and electrically stable.
* Patients with known coronary artery disease should have monitoring until hemodynamically stable and a myocardial infarction is ruled out.
* Echocardiogram is helpful to further evaluate MCC.

Biffl, et al. [3]
Retrospective 4-year review of all patients with high-risk blunt chest trauma
359 107 MCC
14 dysrhythmias
3 cardiogenic shock
with 2 deaths
* Cardiac enzymes (CPK, CKMB) have no useful role in the evaluation of patients with myocardial contusion.
* Risk factors associated with complications from MCC include age > 55, abnormal admission EKG (except sinus tachycardia), absence of chest pain, head injury with GCS < 8, and pelvic fracture.

Cachecho, et al [20]
Retrospective 6-year review of patients with blunt thoracic trauma
336 19 *Young patients with minor blunt thoracic trauma and minimally abnormal EKG do not benefit from cardiac monitoring.
* Evaluation of MCC should not be pursued in hemodynamically stable patients.

Karalis, et al [21]
12-month prospective evaluation of patients admitted with blunt thoracic trauma
105 8 * Only patients who have complications from MCC benefit from echocardiogram. Transesophageal echo may be beneficial if thoracic trauma limits the quality of a trans-thoracic study.

Adams, et al. [22]
12-month prospective evaluation of patients with blunt thoracic trauma
44 2 acute myocardial infarctions Cardiac troponin I accurately detects cardiac injury after blunt chest trauma.

[TableWrap ID: T2] Table 2 

Review of reported coronary artery dissections, treatment strategies, and outcomes


Author/Journal Patient age/sex Mechanism Injury Treatment Outcome
Redondo, et al [11]
Am J Emerg Surg, 2009
45 yo F Motor vehicle collision LMCA-focal stenotic dissection; RCA dissection Angioplasty and heparin Death secondary to intra-abdominal hemorrhage

Goyal, et al. [12]
Heart, 2009
47 yo M Motor vehicle collision LMCA extending to LAD dissection Unknown (no thrombolytics) unknown

Harada, et al. [8]
Ann Thorac Surg, 2002
14 yo M Motorcycle collision LMCA dissection with left ventricular aneurysm Supportive care with surgical patch angioplasty and anuerysmectomy, mitral valvuloplasty and tricuspid annuloplasty 3 weeks later Discharge to home; doing well 4 years post-operatively

Cini, et al [15]
Interact Cardiovasc Thorac Surg, 2008
43 yo F Spontaneous LMCA dissection Surgical revascularization Discharge home

Rogers, et al
Clin Cardiol, 2007
37 yo F
(post-partum)
Spontaneous LMCA with LAD involvement Surgical revascularization Discharge home

Hazeleger, et al. [5]
Circulation, 2001
29 yo M Tackled in football 2 months prior to arrival LAD dissection; OM dissection Stent Discharge home

Smayra, et al. [10]
Am J Thorac Cardiovasc Surg, 2007
17 yo M Unrestrained motor vehicle collision 1 month prior to symptoms LAD dissection Surgical revascularization Discharge home

Korach, et al [9]
Interact Cardiovasc Thorac Surg, 2008
40 yo M Pedestrian struck by automobile LAD dissection Surgical revascularization Discharge home

Leong & Brown [7]
Emerg Med J, 2006
50 yo M Motorcycle collision LAD dissection Bare metal stent + angioplasty after thrombosis Discharge home

Boland, et al. [13]
Chest, 1988
32 yo F Motor vehicle collision at 15 mph 3 days prior to admission LAD & LCx dissection Surgical revascularization Discharge home

Vogiatzis, et al. [16]
Hellenic J Cardiol, 2010
31 yo F (pregnant) Spontaneous LCx dissection Conservative treatment without revascularization Discharge home

Greenberg, et al. [4]
Chest, 1998
35 yo F Water-skiing 2 days prior to arrival Circumflex artery dissection with moderate occlusion Angiogram without intervention Death due to brain death secondary to Vfib arrest prior to emergency department arrival

De Macedo, et al. [17]
J Invasive Cardiol, 2009
34 yo M Spontaneous RCA dissection Stent, heparin, clopidogrel, tirofiban, aspirin Discharge home

Hobelmann[6]
Emerg Med J, 2006
32 yo M Elbow to chest in basketball RCA dissection Eptifibitide and heparin, stent X2 Discharge home

Table 2 Abbreviations: LAD: left anterior descending artery; LCx: left circumflex artery; RCA: right coronary artery; LMCA: left main coronary artery; OM: obtuse marginal artery; Vfib: ventricular fibrillation



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