Aortocoronary dissection complicating angioplasty of chronically occluded right coronary arteries: Is a conservative approach the right approach?

Dissection of the proximal aorta during coronary angiography is a well-recognized and rare complication that occurs more frequently during canalization of a chronically occluded right coronary artery (RCA). Most reported cases describe conservative management or use of intracoronary stents if the entry point is within the coronary artery. Early surgical intervention is rarely advocated or described and might reflect a reporting bias in the cardiology literature. Any patient in whom there is a significant ascending aortic flap should undergo immediate surgical intervention. Clinical Summary PATIENT 1. A 62-year-old woman underwent percutaneous coronary intervention (PCI) for chronic stenoses of the RCA. She had a 1-year history of angina and preserved ventricular function. The RCA was cannulated without difficulty, and the lesion was crossed and dilated. Several attempts were made to pass intracoronary stents, and eventually 3.5-mm stents were placed across proximal and distal lesions with a good angiographic result. At this stage, a dissection flap at the ostium of the RCA was noted, and contrast was clearly seen throughout the wall of the ascending aorta (Figure 1, arrows). A further 3.5-mm stent was deployed at the ostium with apparent success. Echocardiography demonstrated a false lumen in the ascending aorta but no pericardial effusion. After transfer to the coronary care unit, the patient was treated conservatively but the next day experienced intrascapular back pain and inferior electrocardiographic changes. A chest computed tomogram demonstrated an aortic dissection from the ascending aorta to the distal descending aorta. The patient underwent emergency replacement of the ascending aorta and coronary artery bypass grafting to the mid-RCA and conus branch. At the time of the operation, the dissection originated at the RCA ostium and involved the whole of the ascending, arch, and descending aorta, as well as the noncoronary and right coronary cusps. The aortic valve was resuspended. The patient was returned to the intensive care unit on inotropes.