Background

When dissection of a coronary artery involves the ascending aorta, surgical intervention immediately comes to mind as the only choice for repair. However, percutaneous treatment can be an option to seal the aortic dissection and salvage the involved coronary artery.

Case

An 85 year old female presented with chest pressure and elevated troponin. She was taken for cardiac catheterization where left and right coronary systems were patent. Attempt to better engage the right coronary artery (RCA) resulted in an iatrogenic ostial RCA dissection extending to the aortic root (Fig 1A-B).

Decision-making

Stat echocardiogram ruled out pericardial effusion (Fig 1C). In coronary artery dissection encompassing the root, it is imperative to determine extent of aortic involvement. Computed tomography revealed a localized collection of contrast, but no obvious dissection flap (Fig 1D). After reporting jaw pain, stat ECG showed inferior ST elevations (Fig 1E). Decision was made to perform percutaneous coronary intervention (PCI) after a heart team discussion. A wire was advanced to the distal RCA and intravascular ultrasound (IVUS) confirmed entry in the true lumen (Fig 1F). A drug-eluting stent was deployed in the ostium (Fig 1G). Repeat IVUS showed good stent apposition and complete dissection coverage (Fig 1H).

Conclusion

Iatrogenic aorto-coronary dissection is uncommon, but can be safely managed with PCI if extension to the ascending aorta is stable. Imaging is vital to ensure safe and optimal results.

Footnotes