Resolution of iatrogenic aortic dissection illustrated by computed tomography.

An 83-year-old man with known history of known coronary artery disease (prior coronary artery bypass surgery and percutaneous coronary intervention), hypertension, and hypercholesterolemia presented with ongoing exertional angina and dyspnea despite medical therapy. A dipyridamole rubidium-82 stress test showed moderate-sized ischemia in the inferior and inferolateral territory. An echocardiogram showed mild segmental left ventricular dysfunction with an ejection fraction of 45% and mild mitral regurgitation. Angiography showed severe native triple vessel disease, patent left internal mammary artery graft to left anterior descending artery, patent stents in saphenous vein graft to obtuse marginal, and occluded vein graft to right coronary artery (RCA; previously known to be occluded). The native RCA was diffusely diseased with subtotal occlusions in its mid and distal segments including severe proximal posterior descending artery disease and was partly collateralized from obtuse marginal (Figure 1A). Given the ongoing symptoms on medical therapy, decision was made to proceed with percutaneous coronary intervention to RCA. The RCA ostium was engaged with an 8F Amplatz (AL 0.75) guide (chosen for extra support in a calcified, diffusely diseased artery), and the total occlusions in the mid and distal RCA were crossed using a PT Graphix guide wire (Boston Scientific, Natick, Mass). Rotational atherectomy with 1.50-mm burr was performed to recanalize the entire RCA from mid vessel to posterior descending artery because the mid vessel lesion could not be crossed with 1.5-mm balloon. A localized dissection was noted in the proximal RCA, most likely induced by the guiding catheter rather than atherectomy, because it was close to the edge of the guiding catheter and proximal to the segments treated with rotational atherectomy. Gentle balloon inflation was performed in the mid and proximal RCA (3.0-mm compliant balloon to 4 atmospheres). A gentle puff of contrast after the balloon inflation showed propagation of the dissection proximally back to the right coronary sinus and ascending aorta. A 3.5 23 mm Xience stent (Abbott Vascular, Abbott Park, Ill) was immediately deployed to the RCA ostium to seal the entry site of the dissection (Figure 1B). There was no hemodynamic compromise or any evidence of aortic regurgitation. The rest of the RCA was stented with multiple Xience stents and postdilated with excellent final angiographic result (Figure 1C). At angiography, the aortic dissection seemed to be confined to the sinus of Valsalva. Transthoracic echocardiogram showed ascending aortic dissection without aortic regurgitation or pericardial effusion.