Acute myocardial infarction without angiographic luminal narrowing: A case of iatrogenic whole coronary artery dissection

Abstract

A 61-year-old man was referred to the Seoul National University Hospital (Seoul, Korea) from another hospital due to chest pain and ST segment elevation during coronary angiography. The electrocardiogram performed on arrival showed ST segment elevations in inferior leads, suggesting an inferior acute myocardial infarction (Figure 1A). The patient was sent to the cardiac catheterization room for emergency angiography. There was no significant luminal narrowing of the left coronary artery. The right coronary angiogram showed normal coronary flow without obvious angiographic obstruction, despite continued typical symptoms and electrocardiogram changes of acute inferior wall myocardial infarction (Figure 1B). A subsequent intravascular ultrasound (IVUS) revealed dissection of the entire right coronary artery (RCA) from the ostium to the far distal portion (Figure 2A). Angiography performed after pulling back the catheter just out of the RCA ostium showed perivascular staining just distal to the ostium, suggesting iatrogenic dissection of the entire RCA (Figure 2B). After stenting at the RCA ostium, perivascular contrast dye staining disappeared, the patient’s symptoms were relieved and the ST segment elevation was resolved (Figure 2C). At the six-month follow-up, right coronary angiography showed a patent stent, and IVUS revealed complete resolution of the coronary artery dissection (Figure 2D).