Computerized Tomography is an Effective Modality to Evaluate Iatrogenic Aortocoronary Dissection with Acute Myocardial Infarction

Abstract

Unfortunately, right coronary artery (RCA) of a 55-year-old man with unstable angina was spirally dissected from ostium into mid-RCA during manipulation of a guiding catheter and extended to coronary sinus of aortic root (Figure 1). A guidewire could not be introduced into the true lumen. Intravascular ultrasonography-guided wiring could not be attempted due to emergent situation. After initiating medical therapy, chest pain and ST-segment elevation were resolved and hemodynamic status was stabilized. Computerized tomography (CT) performed on the third day showed extended dissection of aortic root was localized at sinus of Valsalva without propagation into ascending aorta (Figure 2). The 7-day follow-up angiography showed collateral flow (Rentrop grade 2) to distal-RCA (Figure 3). Conservative management was maintained for aortic root dissection and delayed percutaneous coronary intervention (PCI) was planned for RCA dissected and totally occluded without surgery. After 3 months, angiography showed no significant change of RCA dissection with slit-like true lumen (Figure 4A). PCI was strugglingly performed from distal-RCA to ostium with 4 stents (Resolute Onyx™) (Figure 4B and C). Then, effort angina was completely improved. Iatrogenic dissection of coronary artery is an uncommon but life-threatening complication.1) When dissection extends to the aortic root and ascending aorta, it should be meticulously evaluated and managed as quickly as possible.2) 3) CT is a helpful and effective tool to evaluate a range of extended dissection flap. If dissection flap is localized and hemodynamic status is stable, conservative management and delayed PCI would be a treatment option for aortocoronary dissection despite acute myocardial infarction.4) 5)