Treatment of aortocoronary dissection complicating anomalous origin right coronary artery and chronic total intervention with intravascular ultrasound guided stenting

Abstract

Acute dissection of the ascending aorta is a rare complication of percutaneous coronary intervention (PCI). Its mechanism involves disruption of the coronary intima by mechanical trauma, followed by subintimal injection of contrast, which, in turn, contributes to subsequent extension of the dissection. In contrast to spontaneous aortic dissection of ascending aorta, which mandates immediate surgical intervention, the appropriate therapy and outcome of this rare entity are not well established. We report a case of iatrogenic aortocoronary dissection, complicating transradial PCI for recanalization of anomalous origin right coronary artery (RCA) from the left coronary cusp with chronic total occlusion. The intimal tear was created by a balloon rupture in the proximal RCA, with propagation of dissection into the ostium and the coronary sinus of Valsalva. Intravascular ultrasound (IVUS) guided coronary stenting was performed to seal the entry port, and to break down the dissection route. This case indicates that IVUS can be a useful tool to ensure complete coverage of the intracoronary dissection and precise placement of the stent to fully cover the ostium of the culprit vessel. This can be particularly important in difficult situations, such as anomalous origin of RCA from the left cusp, with acute downward anterior angulation.