Iatrogenic right coronary artery dissection distal to a total occlusion: a case report

Right coronary artery dissection after aortic valve replacement presenting with refractory ventricular fibrillation

Iatrogenic coronary artery dissection is a rare complication seen in 0.07% of coronary procedures. Presentations of this condition vary, ranging from signs of myocardial ischemia to rarer presentations of ventricular arrhythmias. We present a rare case of a 55-year-old patient with native aortic valve endocarditis who developed right coronary artery dissection (RCAD) in the immediate post-op period presenting with refractory ventricular fibrillation (VF). Emergency coronary angiogram revealed an extensive RCAD extending from the ostium to the mid-vessel as the cause of VF. A consensus between the cardiologists and the cardiac surgeons led to an emergency right coronary artery bypass graft (CABG) that resolved the VF. This case illustrates a rare presentation of iatrogenic RCAD and the successful management of the same. We highlight the importance of prompt detection via angiography in patients suspected of having coronary artery dissection and showcase the successful implementation of emergency CABG in a patient with unstable haemodynamics.

The novel use of retrograde CTO PCI techniques as a rescue strategy for an acute right coronary artery occlusion due to iatrogenic dissection

Coronary artery dissection is a known complication of percutaneous coronary intervention (PCI). Such dissections are often treated by antegrade PCI. When antegrade PCI fails, the options become limited to conservative management or coronary artery bypass grafting (CABG). CABG comes with its own risks, and conservative management can result in a potentially larger infarct. Here we present a novel use of retrograde chronic total occlusion (CTO) PCI techniques to treat an iatrogenic, type D dissection of the right coronary artery in a young male with an acute coronary syndrome. Reentrance of the true lumen by standard antegrade approaches failed. The rescue strategy using a retrograde CTO PCI approach not only had advantages over surgery and conservative management, but also over antegrade PCI. A soft wire, designed for collaterals, was used to "surf" the dissection and reach the antegrade guiding catheter. Thus, the true lumen could be used. This novel approach provided the advantages both of preserving major side branches, which are often lost with antegrade PCI approaches, and of not unnecessarily puncturing the dissection membrane. <Learning objective: Extensive iatrogenic coronary artery dissections not amenable to antegrade PCI are typically managed conservatively or by CABG. A novel, bail-out strategy using retrograde CTO PCI techniques provided another treatment strategy. A soft wire, designed for collaterals, was used to "surf" the dissection and reach the antegrade guiding catheter. This method has the great advantage of preserving major side branches, which are often lost with antegrade PCI approaches.>.

Emergency Coronary Artery Bypass Graft Surgery for Iatrogenic Left Main Coronary Artery Dissection

Iatrogenic coronary artery dissection during coronary angiography with or without rupture is a rare but feared complication. We herein report a case of iatrogenic left main coronary artery dissection in a 49-year-old female. Admitted to our hospital with a recent history of severe hypotension, she develpled apnea during angiography. She was intubated and resuscitated with an Epinephrine infusion in the Cath-Lab. The diagnosis was iatrogenic left main coronary artery dissection based on angiography. Immediately, the patient was transferred to the operating room in a lethargic state with an Epinephrine infusion and prepared for emergency coronary artery bypass graft surgery. In the ICU, she was completely alert with no hemodynamic complications and finally was discharged in a good overall condition. At 18 months' follow-up, the patient was in a stable situation with good daily function.