Iatrogenic Aortocoronary Dissection Successfully Treated by Coronary Intervention

Abstract

A 77-year old male retired decorator presented with an 18-month history of exertional dyspnea. Coronary angiography was performed via the right femoral artery using 6 French JL4 and JR4 diagnostic catheters. A catheter possibly seated in a plaque caused dissection of the right coronary artery with the injection of the contrast. Timely coronary intervention with stenting resulted in sealing the entry point with complete healing of the aortic root and TIMI-3 patency of the right coronary artery. Major cardiac surgery was, therefore, averted. Case Report A 77-year old male retired decorator presented with an 18-month history of exertional dyspnea, predominantly on walking uphill. His exercise tolerance was two miles on a flat surface. He denied chest pains. He did not complain of paroxysmal nocturnal dyspnea (PND), orthopnea or pedal edema. Past medical history included hypertension, gout and paroxysmal atrial fibrillation. He was a non-smoker and drank 7 units of alcohol a week. Echocardio gram (ECG) showed left bundle branch with QRS duration of 175 ms and severe left ventricular (LV) impairment with ejection fraction of 25% with global hypokinesia. Valves were normal in appearance. Coronary angiogram was programmed to rule out ischemic etiology. Coronary angiography was performed via the right femoral artery using 6 French JL4 and JR4 diagnostic catheters. Coronary angiography of the left arterial system showed significant stenoses in LAD and LCX. One image of the RCA was obtained and this showed diffuse significant disease proximally and in the mid-course. There was no damping of pressure prior to injection. Unfortunately, a catheter possibly seated in a plaque caused dissection of the RCA with the injection of the contrast. The dissection plane from proximal RCA extended retrograde into the aortic root (Figure 1, Video 1). The patient experienced chest pain with slight ST elevation in inferior leads. There was no drop in blood pressure. We proceeded to coronary intervention with the intention of sealing the entry point of the dissection in proximal RCA. The lesion in the RCA was crossed with BMW (balance middle weight wire), predilated with Ryugin 1.25¥15 mm, maverick 2¥12 mm and sprinter 2.5¥20 mm balloons. Proximal RCA was stented up to ostium with Liberte 2.75¥20 mm stent and more distally with Liberte 2.5¥18 mm stent. A CT scan was taken post procedure and this showed dissection involving 50 mm of ascending aorta from the right coronary ostium (Figures 2 and 3). Repeat CT performed two days later revealed that the contrast was no longer visible and there was no suggestion of persistent dissection flap (Figure 4). The aortic root appeared to be completely healed with no convincing residual dissection. Further more, the stent appeared to be placed in an excellent position just at the ostium of the RCA.