Stanford A型急性大動脈解離・左冠状動脈灌流不全に対して経皮的冠状動脈形成術を先行させた1例

Primary Percutaneous Coronary Intervention for Acute Aortic Dissection with Left Coronary Artery Malperfusion：Report of a Case

はじめに　急性大動脈解離（acute aortic dissection：AAD）に左冠状動脈主幹部（left main coronary artery：LMCA）の灌流不全（malperfusion：MP）を合併するのは3.01）～4.3％2）と比較的まれである．ほとんどの症例で心原性ショックとなり，およそ半数で心肺停止をきたすとされ3），救命は困難をきわめる．LMCAのMPを合併したStanford A型AADに対して，経皮的心肺補助（percutaneous cardiopulmonary support：PCPS）下に経皮的冠状動脈形成術（percutaneous coronary intervention：PCI）を先行させ，その後に上行大動脈置換（ascending aortic replacement：AAR）を行い救命しえた1例を経験したので，文献的考察を加え報告する．

Left main coronary artery （LMCA） malperfusion due to acute aortic dissection （AAD） is relatively rare but life-threatening. Almost all such patients suffer from cardiogenic shock, and cardiopulmonary arrest occurs in approximately half of them. A 64-year-old man with chest pain was taken to our hospital by ambulance. Acute coronary syndrome was suspected as electrocardiography showed changes in ST segment. Coronary angiography revealed severely stenotic LMCA. Percutaneous cardiopulmonary support was initiated for subsequent cardiogenic shock. Dissection in the LMCA on intravascular ultrasonography suggested that AAD occurred and dissection extended into the LMCA. Percutaneous coronary intervention （PCI） to the LMCA was performed with a drug-eluting stent. Post-PCI contrast-enhanced computed tomography （CT） scan demonstrated Stanford type A AAD. Subsequently, ascending-aortic replacement was successfully carried out. Postoperative echocardiography showed well preserved cardiac contraction. Primary PCI under percutaneous cardiopulmonary support for AAD and LMCA malperfusion shortens myocardial ischemic time and improves prognosis.