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. Figure 1. RCA angiographic appearance: preprocedure (A), contrast in the false lumen of the aortic root dissection originating from RCA ostium (image at the time of ostial stent deployment) (B), and final angiographic appearance (C). 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 …