One of the most feared complications of percutaneous coronary interventions is coronary artery dissection. Rarely, such dissections can propagate into the ascending aorta, which may then require surgical intervention. We present the case of a 50-year-old patient with new-onset angina and two-vessel coronary artery disease who underwent percutaneous coronary intervention on the right coronary artery, complicated by an iatrogenic coronary dissection extending into the ascending aorta. A decision was taken to perform emergent cardiac surgery due to ongoing chest pain and the extent of the dissection. Computed tomography after surgery revealed no signs of aortic dissection with normal dimensions in all aortic segments. The patient was discharged home in a stable condition.

iatrogenic dissection, percutaneous coronary intervention

Coronary artery dissection during percutaneous coronary interventions (PCI) presents a complex and challenging scenario for clinicians, sometimes necessitating surgical intervention for resolution. The latter is especially valid in cases of coronary artery dissection extending to the aorta. While PCI has revolutionized the management of coronary artery disease, the occurrence of iatrogenic aortic dissection remains a rare but potentially life-threatening complication. This phenomenon encompasses a spectrum of clinical presentations ranging from asymptomatic cases to acute coronary syndromes and hemodynamic instability leading to cardiogenic shock and death. The decision-making process regarding the optimal management strategy requires a thorough understanding of the underlying pathophysiology, risk factors, diagnostic modalities, and available treatment options. In this case report, we aim to explore the current understanding, challenges, and advancements in the management of coronary artery dissection extending to the aorta during PCI, focusing on the indications and outcomes of surgical intervention in these complex cases.

A 50-year-old woman was admitted to a secondary hospital with a new onset of typical chest pain on exertion. Her overall condition was satisfactory with no pathologic findings on physical exam. Her blood pressure was 120/70 mmHg and her heart rate was 72 bpm. No significant ST-segment deviation on ECG was observed (Fig. 1) and conventional troponin was within reference ranges.

Figure 1.

ECG obtained on admission.

Transthoracic echocardiography (TTE) revealed a preserved left ventricular ejection fraction (59%), normal valve function, and no wall motion abnormalities (WMA). Her risk factors for coronary artery disease (CAD) were hypertension and hyperlipidemia. She did not report any family history of CAD or smoking. She had been taking a fixed combination of perindopril/indapamide/amlodipine 5/1.25/5 mg daily and levothyroxine 50 mcg due to underlying hypothyroidism. Although her GRACE score was low at 88, the patient was referred for coronary angiography due to the very typical angina symptoms. ^[1] Angiography revealed a 70% stenosis of the left circumflex (LCx) artery and a critical lesion in the middle segment of the right coronary artery (RCA) (Figs 2, 3) .

Figure 2.

A 30° caudal projection showing LCx with a 70% stenosis (white arrow).

Figure 3.

A 30° left anterior oblique (LAO) view of the RCA showing two critical stenoses from the proximal to the middle segment of the RCA (white arrows).

A decision was taken to perform PCI of the RCA. A Judkins right (JR) 3.5 guiding catheter was used to engage the RCA. Since there was difficulty crossing the lesion with a workhorse guidewire, a 1.5×10 mm balloon was used for better support. At this moment, the patient complained of chest pain and ST-segment elevations were observed on the ECG monitor. A small contrast injection showed dissection in the middle segment of RCA, starting from the proximal part (Fig. 4) . Fortunately, the guidewire now seemed to have crossed the lesion. However, when a second contrast injection was performed to check the position of the latter, a retrograde dissection was observed which extended to the right coronary cusp and ascending aorta (Fig. 5) .

Figure 4.

A dissection is seen from the proximal to the middle segment of the RCA (white arrow). There is minimal to no blood flow distal to the dissection (white arrowheads).

Figure 5.

The moment when the dissection extended proximally to the right aortic cusp (white arrow) is caught on fluoroscopy. The guidewire is placed distally in a right ventricular branch (white arrowhead).

Immediate implantation of a drug-eluting stent (DES) 3.0×24 mm and post-dilatation with a non-compliant (NC) balloon 3.5×10 mm at the ostium of the RCA was performed at 24 atm (Fig. 6) . Despite no blood flow (TIMI 0) in the distal RCA and the aortic dissection (Fig. 7) , the patient remained stable with mild to moderate chest pain, in normal sinus rhythm with a heart rate of 90 bpm and blood pressure of 105/70 mmHg. Several unsuccessful distal recanalization attempts were made.

Figure 6.

A drug-eluting stent 3.5×24 mm (white arrow) being placed at the ostium of the RCA is seen. The contrast from the previous injection is trapped within the false lumen of the ascending aorta (white arrowheads).

Figure 7.

There is no distal in the RCA below the level of the arrow. Interestingly enough, there is also no aortic regurgitation visible (white arrowhead).

After discussing the case with cardiac surgeons, the patient was transferred to a tertiary hospital with a cardiovascular surgery on site. She was admitted after midnight, approximately 3 hours after the dissection. ECG on admission showed ST-elevations, most prominent in lead III, and ST-depressions with negative T-waves in lead I and aVL (Fig. 8) . Computed tomography (CT) was performed (Figs 9, 10) .

Figure 8.

ECG on admission with ST-elevations in lead III, and ST-depressions with negative T-waves in lead I and aVL.

Figure 9.

Native CT showing the false lumen (white arrow) with trapped contrast from the coronary angiography.

Figure 10.

CT with contrast showing the extent of the dissection (black arrow).

The heart team decided to operate immediately (5 hours after PCI) using two saphenous vein grafts (SVGs) to the RCA and LCx. Since there was no aortic regurgitation on the pre-op TTE, only milking of the aorta was performed without replacement of the aortic valve, nor of the ascending aorta. On post-op transthoracic echocardiography akinesia of the inferior wall and posterior septum was observed with a left ventricular ejection fraction (EF) of 52%. CT after surgery revealed no signs of aortic dissection with normal dimensions in all aortic segments (Fig. 11) .

Figure 11.

Post-operative CT with contrast showed no signs of aortic dissection. SVG: saphenous vein graft; RCA: right coronary artery.

The patient was discharged on the 7th postoperative day in a stable condition with Q-waves in the inferior leads (Fig. 12) and persisting wall-motion abnormalities in the inferior wall.

Figure 12.

ECG on discharge showing Q-waves in the inferior leads and several premature ventricular contractions (PVCs).

At one-year follow-up, the patient reported having normal physical activity without any symptoms of angina.

Although coronary artery dissections during PCI, especially small non-flow limiting ones, are not that uncommon, most of them are asymptomatic, or their entries are easily sealed off by stenting.^[2–4] Rarely, however, coronary dissections may extend to the ascending aorta. In the landmark publication of Dunning et al., the authors categorize such dissections into 3 classes with class I dissection involving the aortic cusp only, class II involving the cusp and extending up the aorta less than 40 mm, and class III dissections involving the aorta more than 40 mm in length.^[5] The patient presented in this case report had a class III dissection and similarly to the patients in the previously cited publication required surgical intervention due to the extent of the dissection and ongoing chest pain as a result of distal vessel occlusion. In another more recent publication by Gennari et al., the authors describe a similar strategy; however, unlike our approach, they recommend ascending aorta replacement in class III dissections.^[6]

Several learning points can be made based on the presented case report and the literature review of similar published cases. First of all, most iatrogenic aortic dissections occur during angiography or PCI of the right coronary artery (RCA) and even small contrast injections may help an initially small dissection extend up the coronary cusp and involve the ascending aorta. In such cases, immediate stenting of the dissection entry site should be attempted to seal the dissection and prevent its progression without further contrast injections. Surgical intervention should be used only in select cases such as when the dissection involves more than 40 mm of the ascending aorta and there is at least one of the following: hemodynamic compromise, severe acute aortic regurgitation, hemopericardium, inability to seal the dissection entry site, or distal vessel occlusion. Lastly, surgical intervention does not always have to involve replacing the ascending aorta even in class III dissections.

In conclusion, prompt recognition, decisive interventional strategies, and careful consideration of surgical options are paramount in managing iatrogenic coronary artery dissections extending to the ascending aorta.

We acknowledge our thanks to Drs. Delyan Evrev and Petyu Mishev for providing their professional expertise on the case.

The authors have no funding and no support to report.

The authors have declared that no competing interests exist.