Dissecting hematoma (aneurysm) of coronary arteries

doi:10.1016/0002-9343(86)90032-X

The American Journal of Medicine

Volume 80, Issue 2, February 1986, Pages 317-319

https://doi.org/10.1016/0002-9343(86)90032-X Get rights and content

Abstract

Isolated dissecting hematoma (aneurysm) of a coronary artery is a rare occurrence that often results in myocardial infarction and sudden death. A case of dissecting hematoma involving the left main, left anterior descending, and left circumflex coronary arteries is described in a patient who had received vigorous closed-chest cardiac resuscitation. This is believed to be the first reported case of coronary artery dissection caused by epicardial trauma from closed-chest cardiac resuscitation. This case demonstrates that dissecting hematoma of the coronary artery can be a complication of cardiac resuscitation.

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A systematic review and pooled analysis of CPR-associated cardiovascular and thoracic injuries
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Citation Excerpt :
Other significant cardiac complications of CPR including intracavitary hematoma,35 prosthetic valve dehiscence,30 papillary muscle rupture,36 and conductions system injuries that occurred in up to 10% of patients in one report.37 Major vascular complications (Table 2) including aneurysm, pseudoaneurysm, dissection, laceration or rupture to the coronary vasculature,37–42 coronary bypass grafts,43 aorta,8,10,11,17,32,44–47 subclavian artery and vein, and the vena cava6 may also occur following both manual and ACD-CPR (Fig. 2). Notably, among patients that fail to recover from cardiac arrest after CPR, fractures of the coronary arteries, often at multiple sites have been described.39
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Nine-hundred twenty-eight potentially relevant references were identified. Twenty-seven references met inclusion criteria.
A systematic review of the literature is provided with pooled data analysis.
The incidence of reported CPR-associated cardiovascular and thoracic wall injuries varies widely. CPR with active compression–decompression devices has a higher reported incidence of cardiopulmonary injuries. Bedside ultrasound may be a useful adjunct to assess and risk-stratify patients to identify serious or life-threatening CPR-associated injuries.
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Isolated, spontaneous dissection of the coronary arteries in the absence of trauma is an unusual but well-documented occurrence. Fewer than 50 cases have been reported in males in the English language literature, and only one case, nonfatal, was associated with cocaine use. We present the second overall and the first fatal case of cocaine-associated spontaneous coronary artery dissection and a brief review of the literature on coronary dissection and the cardiovascular effects of cocaine use. The mechanism of cocaine's toxicity on the heart and vasculature is complex, multifactorial, and predominantly related to cocaine's adrenergic properties. The increased arterial blood pressure from cocaine's inotropic and chronotropic effects combined with its direct vasoconstrictive effect leads to increased shear forces on the coronary endothelium. This elevated stress may be responsible for the formation of an intimal tear and the subsequent dissection of the coronary artery. If the dissected portion of the arterial wall is displaced enough to significantly occlude the true lumen, infarction can result. In light of this possibility, coronary artery dissection must be considered in young patients presenting with symptoms of cardiac ischemia and a history of cocaine use.
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We present the clinical and postmortem findings in seven adults (four females and three males), who died with dissection of the coronary arteries. The median age was 56 years. Five of the coronary artery dissections (CADs) were spontaneous and two followed trauma: one a motor vehicle accident, the other occurred during angiography. Four cases died suddenly or within 30 minutes. Three had symptoms of at least 24 hours duration and, not unexpectedly, had histological evidence of myocardial infarction. Four dissections involved the left anterior descending coronary artery, two the right coronary artery and one a dominant circumflex artery. Histological examination of the dissected arteries in four cases demonstrated necrosis of the medial smooth muscle which was intimately related to intimal tears and/or an inflammatory reaction. From a review of the literature and this study of seven cases, we conclude that CAD is multifactorial in causation and has a wide spectrum of clinical presentations. Presently the role of coronary vasospasm and prior trauma appears underestimated, and in many cases of CAD the nature of the primary initiating event remains open to speculation.
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^☆: The opinions expressed in this manuscript are those of the authors and not necessarily those of the United States Air Force or the Department of Defense.

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Case reportDissecting hematoma (aneurysm) of coronary arteries☆

Abstract

J Thorac Cardiovasc Surg

Am J Med

Am J Cardiol

Am Heart J

Dissecting aneurysm of coronary artery in a woman aged 42: rupture

Br Med J

Dissecting aneurysms of coronary arteries

Arch Pathol

Dissecting aneurysm of the aorta: a review of 505 cases

Medicine (Baltimore)

Postpartum coronary artery dissection

Br Heart J

Two dissecting coronary artery aneurysms postpartum

N Engl J Med

Dissecting aneurysm of coronary artery

NZ Med J

Multiple coronary artery dissections in old age

Arch Pathol Lab Med

Case report
Dissecting hematoma (aneurysm) of coronary arteries☆