Coronary artery dissection is a rare complication of blunt chest wall trauma. We report a case of acute left anterior descending and right coronary artery dissections after a motor vehicle accident. The musculoskeletal injuries obscured the cardiac symptoms. Electrocardiogram and bedside echocardiogram revealed cardiac pathology, which prompted urgent coronary angiography and intervention. (Level of Difficulty: Advanced.

Birnbaum, Gilad

Hamzeh, Ihab

Kayani, Waleed

Lakkis, Nasser

Owen, Brittany

Pandey, Yagya

Tabbaa, Rashed

English

PubMed

DigitalCommons@The Texas Medical Center

The Texas Medical Center Library DigitalCommons@TMC Faculty and Staff Publications Baylor College of Medicine 12-1-2020 Multivessel Traumatic Coronary Artery Dissection After a Motor Vehicle Accident With Successful Percutaneous Coronary Intervention Yagya Pandey Brittany Owen Gilad Birnbaum Rashed Tabbaa Ihab Hamzeh See next page for additional authors Follow this and additional works at: https://digitalcommons.library.tmc.edu/baylor_docs  Part of the Cardiology Commons, Cardiovascular Diseases Commons, and the Medical Sciences Commons Recommended Citation Pandey, Yagya; Owen, Brittany; Birnbaum, Gilad; Tabbaa, Rashed; Hamzeh, Ihab; Lakkis, Nasser; and Kayani, Waleed, "Multivessel Traumatic Coronary Artery Dissection After a Motor Vehicle Accident With Successful Percutaneous Coronary Intervention" (2020). Faculty and Staff Publications. 998. https://digitalcommons.library.tmc.edu/baylor_docs/998 This Article is brought to you for free and open access by the Baylor College of Medicine at DigitalCommons@TMC. It has been accepted for inclusion in Faculty and Staff Publications by an authorized administrator of DigitalCommons@TMC. For more information, please contact digcommons@library.tmc.edu. Authors Yagya Pandey, Brittany Owen, Gilad Birnbaum, Rashed Tabbaa, Ihab Hamzeh, Nasser Lakkis, and Waleed Kayani This article is available at DigitalCommons@TMC: https://digitalcommons.library.tmc.edu/baylor_docs/998 MINI-FOCUS ISSUE: CHEST WOUNDSCASE REPORT: CLINICAL CASEMultivessel Traumatic Coronary ArteryDissection After a Motor Vehicle AccidentWith Successful PercutaneousCoronary InterventionYagya Pandey, MD,* Brittany Owen, MD,* Gilad Birnbaum, MD, Rashed Tabbaa, MD, Ihab Hamzeh, MD,Nasser Lakkis, MD, Waleed Kayani, MDABSTRACTCoronary artery dissection is a rare complication of blunt chest wall trauma. We report a case of acute left anteriordescending and right coronary artery dissections after a motor vehicle accident. The musculoskeletal injuries obscured thecardiac symptoms. Electrocardiogram and bedside echocardiogram revealed cardiac pathology, which prompted urgentcoronary angiography and intervention. (Level of Difficulty: Advanced.) (J Am Coll Cardiol Case Rep 2020;2:2295–8)© 2020 The Authors. Published by Elsevier on behalf of the American College of Cardiology Foundation. This is an openaccess article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).HISTORY OF PRESENTATIONA 63-year-old man presented to our level I traumacenter after a motor vehicle collision. On the scene,he was found conscious, in the driver’s seat, and hadhis right knee forcibly flexed to his chest. He wastransported to the emergency department after aprolonged 45-min extrication. On arrival, the patientwas hemodynamically stable. He was not in visibledistress, but he did endorse diffuse pain throughouthis chest wall and all extremities. Physical examina-tion was significant for limb deformities and repro-ducible chest wall tenderness. An electrocardiogram(ECG) performed in the emergency department(Figure 1) showed sinus rhythm and ST-segment ele-vations in the lateral and anterior leads.MEDICAL HISTORYThe patient’s medical history was significant for hy-pertension and hyperlipidemia.INVESTIGATIONSThe patient’s initial troponin level was 0.94 ng/dl(normal <0.04 ng/dl). Thoracic imaging with chestradiograph and computed tomography (CT) scan ofLEARNING OBJECTIVES To recognize that blunt chest wall traumamay cause coronary artery dissections andcardiac ischemia. To evaluate patients with blunt chest walltrauma for cardiac ischemia by performing ascreening ECG and point-of-careechocardiography. To coordinate with the trauma surgery teamto prioritize coronary angiography and in-terventions if cardiac ischemia is suspected.ISSN 2666-0849 https://doi.org/10.1016/j.jaccas.2020.09.021From the Baylor College of Medicine, Ben Taub General Hospital, Houston, Texas, USA. *Drs. Pandey and Owen contributedequally to this work.The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information,visit the Author Center.Manuscript received August 13, 2020; revised manuscript received September 8, 2020, accepted September 18, 2020.J A C C : C A S E R E P O R T S V O L . 2 , N O . 1 5 , 2 0 2 0ª 2 0 2 0 T H E A U T H O R S . P U B L I S H E D B Y E L S E V I E R O N B E H A L F O F T H E A M E R I C A NC O L L E G E O F C A R D I O L O G Y F OU N D A T I O N . T H I S I S A N O P E N A C C E S S A R T I C L E U N D E RT H E C C B Y - N C - N D L I C E N S E ( h t t p : / / c r e a t i v e c o mm o n s . o r g / l i c e n s e s / b y - n c - n d / 4 . 0 / ) .the thorax with contrast revealed numerousbilateral rib fractures, no sternal fracture,and no evidence of aortic dissection or tran-section. A bedside echocardiogram showedapical wall hypokinesis with moderatelyreduced left ventricular ejection fraction anda small pericardial effusion.DIFFERENTIAL DIAGNOSISThe initial differential diagnosis included ST-segmentelevation myocardial infarction, cardiac contusion,and stress-induced cardiomyopathy.MANAGEMENTEmergent angiography was initially deferred in thecontext of polytrauma and suspected cardiac contu-sion. However, evidence of evolving infarction on asubsequent ECG prompted us to proceed with urgentcoronary angiography after a bedside closed reduc-tion of his dislocated right hip by orthopedic surgeryto avoid femoral head necrosis.Coronary angiography (Figure 2, Video 1) showedthe following: 1) an acute dissection of the proximalleft anterior descending (LAD) artery with Throm-bolysis In Myocardial Infarction (TIMI) flow grade 0;2) dissection of the right coronary artery (RCA) withTIMI flow grade 3; and 3) a patent anomalous leftcircumflex coronary artery arising from the rightcoronary cusp. Successful percutaneous coronaryintervention of the LAD with balloon dilation and 2overlapping everolimus-eluting stents was performedwith restoration of TIMI flow grade 3. The RCA wasmedically managed.FOLLOW-UPRepeat echocardiogram (Video 2) showed a left ven-tricular ejection fraction of 30% and an apical leftventricular thrombus. The patient was discharged onaspirin, ticagrelor, and warfarin. He was doing well athis follow-up appointment.DISCUSSION: ASSOCIATION WITHCURRENT GUIDELINES/POSITION PAPERS/CURRENT PRACTICECardiac complications of blunt chest wall trauma areincreasingly seen in trauma centers as emergencymedical services become more efficient in stabilizingand transporting patients. Potential cardiac compli-cations include cardiac contusions, arrhythmias,pericardial tamponade, ventricular wall lacerationsfrom sternal fractures, valvular lesions, and torsion ordissection of the great vessels (1). Traumatic coronaryartery dissection is a less common complicationdescribed in only a few case reports. This literaturesuggests that the LAD is more commonly affectedthan the RCA and circumflex coronary arteries due toits anterior position (76% vs. 12% and 6%, respec-tively) (2,3). Per our review, this is 1 of 3 casesFIGURE 1 Admission ElectrocardiogramAdmission electrocardiogram demonstrating sinus rhythm and ST-segment elevations in the lateral and anterior leads.ABBR EV I A T I ON SAND ACRONYMSCT = computed tomographyECG = electrocardiogramLAD = left anterior descendingcoronary arteryRCA = right coronary arteryTIMI = Thrombolysis InMyocardial InfarctionPandey et al. J A C C : C A S E R E P O R T S , V O L . 2 , N O . 1 5 , 2 0 2 0Multivessel Traumatic Coronary Artery Dissection D E C E M B E R 2 0 2 0 : 2 2 9 5 – 82296described in which simultaneous traumatic dissectionoccurred in multiple coronary arteries. Traumaticcoronary dissections pose a diagnostic and thera-peutic challenge given vague symptoms, concurrentinjuries needing emergent noncardiac surgery, andthe risk of worsening trauma-related bleeding withanticoagulation.Blunt trauma causes coronary dissection byinducing rapid deceleration and shearing forces,which rupture the endothelium. The dissection isaggravated by tachycardia and hypertension stimu-lated by stress and pain from trauma. As in otherforms of coronary artery disease, rupture of theendothelial wall induces platelet aggregation that canform a thrombus and cause acute myocardial infarc-tion. Blunt chest trauma may also cause infarction byrupturing existing atherosclerotic coronary plaques(3). Further investigation is needed to understandwhether pre-existing atherosclerosis increases therisk of a traumatic myocardial infarction.Multiple factors may obscure the diagnosis oftraumatic acute coronary dissection, and recognitionrequires a high index of suspicion. Review of priordata suggests that neither the mechanism norseverity of injury is predictive, as coronary dissec-tions have been reported from severe motor vehicleaccidents as well as minor sports injuries (4). Com-mon signs and symptoms of cardiac ischemia such aschest pain, diaphoresis, and tachycardia may beattributed to significant musculoskeletal trauma, andcardiac etiologies may be overlooked. Cardiac enzymelevels have limited diagnostic utility in this scenario.Troponin enzyme levels rise to detectable amounts inthe serum 4 to 6 h after myocardial injury (5), wellafter most patients with blunt chest trauma areinitially triaged. Furthermore, cardiac enzyme levelsFIGURE 2 Coronary Angiography(A) Proximal left anterior descending coronary artery dissection with Thrombolysis In Myocardial Infarction flow grade 0. (B) Mid–rightcoronary artery dissection with Thrombolysis In Myocardial Infarction flow grade 3. (C) Post–percutaneous coronary intervention restorationof left anterior descending coronary artery flow.J A C C : C A S E R E P O R T S , V O L . 2 , N O . 1 5 , 2 0 2 0 Pandey et al.D E C E M B E R 2 0 2 0 : 2 2 9 5 – 8 Multivessel Traumatic Coronary Artery Dissection2297may rise due to nonischemic causes of myocardialdamage as well as skeletal muscle injury.All patients who present with blunt chest walltrauma should be assessed for hemodynamic stabilityand have a screening ECG to assess for arrhythmiasand ischemic changes. Any patient with persistentchest pain or ECG changes should be admitted forclose cardiac monitoring with serial measurement oftroponin levels. Although echocardiogram is readilyavailable and frequently used, its role as a risk strat-ification tool in blunt cardiac trauma has been ques-tioned by some investigators (6).Patients with persistent signs of coronary ischemiaeven in the setting of significant trauma should beevaluated by using coronary angiography. However,interventions should be performed in close collabo-ration with the cardiothoracic surgery team.CT scan of the thorax is commonly obtained fortriaging patients with blunt chest wall trauma. In onecase report, a traumatic coronary dissection was seenon initial CT imaging when retrospectively reviewed(7). Furthermore, there is growing evidence that CTangiography is an effective method of visualizingcoronary arteries and spontaneous coronary arterydissections (8–10). In patients with suspected trau-matic coronary artery dissection, CT imaging shouldbe closely reviewed to assess for coronary abnormal-ities. It may evolve as an effective method to quicklyassess for traumatic coronary artery dissection ifinitial clinical suspicion is high. However, furtherstudies are needed to assess the efficacy of CT an-giograms in this clinical scenario, particularly becauseECG gating is not typically performed in the setting oftrauma.CONCLUSIONSThis case highlights the challenges of diagnosingacute coronary dissection in patients with blunt chestwall trauma and underscores the importance of hav-ing a low threshold for further cardiac evaluation iffindings suggestive of coronary ischemia are present.AUTHOR DISCLOSURESThe authors have reported that they have no relationships relevant tothe contents of this paper to disclose.ADDRESS FOR CORRESPONDENCE: Dr. WaleedKayani, Section of Cardiology, Baylor College of Med-icine, Ben Taub General Hospital, 1504 Taub Loop,Houston, Texas 77030, USA. E-mail: kayani@bcm.edu.Twitter: @WKayaniMD.RE F E RENCE S1. Prêtre R, Chilcott M. Blunt trauma to the heartand great vessels. N Engl J Med 1997;336:626–32.2. Abdolrahimi SA, Sanati HR, Ansari-Ramandi MM, Heris SO, Maadani M. Acutemyocardial infarction following blunt chest traumaand coronary artery dissection. J Clin Diagn Res2016;10:OD14–5.3. Lobay KW, MacGougan CK. Traumatic coro-nary artery dissection: a case report andliterature review. J Emerg Med 2012;43:e239–43.4. Atalar E, Açil T, Aytemir K, et al. Acute anteriormyocardial infarction following a mild non-penetrating chest trauma: a case report. Angiol-ogy 2001;52:279–82.5. Babuin L, Jaffe AS. Troponin: the biomarker ofchoice for the detection of cardiac injury. CMAJ2005;173:1191–202.6. Nagy KK, Krosner SM, Roberts RR, Joseph KT,Smith RF, Barrett J. Determining which patientsrequire evaluation for blunt cardiac injuryfollowing blunt chest trauma. World J Surg 2001;25:108–11.7. Allemeersch GJ, Muylaert C, Nieboer K. Trau-matic coronary artery dissection with secondaryacute myocardial infarction after blunt thoracictrauma. J Belg Soc Radiol 2018;102:4.8. Vural M, Aksit Z, Kovanlikaya I, Degertekin M,Demirtas E. Can multidetector CT angiographydetect coronary artery dissection? Tex Heart Inst J2007;34:388–9.9. Torres-Ayala SC, Maldonado J, Bolton JS,Bhalla S. Coronary computed tomography angi-ography of spontaneous coronary artery dissec-tion: a case report and review of the literature. AmJ Case Rep 2015;16:130–5.10. Roura G, Ariza-Solé A, Rodriguez-Caballero IF,et al. Noninvasive follow-up of patients withspontaneous coronary artery dissection with CTangiography. J Am Coll Cardiol Img 2016;9:896–7.KEY WORDS acute coronary syndrome,coronary angiography, dissectionAPPENDIX For supplemental videos,please see the online version of this paper.Pandey et al. J A C C : C A S E R E P O R T S , V O L . 2 , N O . 1 5 , 2 0 2 0Multivessel Traumatic Coronary Artery Dissection D E C E M B E R 2 0 2 0 : 2 2 9 5 – 82298

Multivessel Traumatic Coronary Artery Dissection After a Motor Vehicle Accident With Successful Percutaneous Coronary Intervention

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Multivessel Traumatic Coronary Artery Dissection After a Motor Vehicle Accident With Successful Percutaneous Coronary Intervention

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