Iatrogenic bidirectional dissection of the right coronary artery and the ascending aorta: the worst nightmare for an interventional cardiologist

Abstract

Although rare, iatrogenic aortocoronary dissection is one of the complications most dreaded by the interventional cardiologist. If not managed promptly, it can have redoubted and serious consequences. Herein, we present the case of a 70 year-old woman who was treated by stenting of the second segment of the right coronary artery (RCA) for recurrent angina but, unfortunately, the procedure was complicated by anterograde dissection of the RCA with a simultaneous retrograde propagation to the proximal part of the ascending aorta. Successful stenting of the entry point was able to recuperate the RCA and to limit the retrograde propagation to the ascending aorta, but there was an extension of the dissection to the aortic valve leaflets resulting in a massive aortic insufficiency. Therefore, surgical aortic valve replacement with prosthetic tube graft was performed [corrected].

Keywords: Ascending aorta; Coronary angioplasty; Coronary dissection.

Fig. 1

The dissection line (arrow) at the level of the proximal right coronary artery (A) and the retrograde opacification of the proximal segment of the ascending aortic wall (false lumen) (arrow) highlighting the aortic dissection (B).

Fig. 2

The stagnation of contrast media within several centimeters of the aortic wall and the proximal segment of the right coronary artery (RCA) prior to stenting and the observed bidirectional dissection (A) and the angiographic results following the stenting procedure of the ostium of the RCA (B).

Fig. 3

Computed tomography scans showing the intimal flap with the false lumen (FL) (thick arrow) of the type A aortic dissection (Stanford classification) at the level of the right coronary artery's (RCA) (thin arrow) ostium.