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case_images: Initial Coronary Angiography. (A) Right and (B to D) left coronary vessels. The left coronary vessels are shown in the (B) posteroanterior caudal view, (C) posteroanterior cranial view, and (D) left anterior oblique cranial view. The blue and orange arrows demonstrate the lesions within the left anterior descending artery and a diagonal branch, respectively.
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case_images: Left coronary angiography revealed a significant lesion in the mid-left anterior descending (LAD) artery and the first diagonal (D1) branch (Figures 1A to 1D). This test resulted in contrast staining within the aorta, a finding suggesting that there had been an aorto-ostial dissection (Figure 2B, Video 1).
case_images: Left Coronary Angiography Before and After Wire Removal. Angiography of the (A) left anterior descending artery and diagonal branch and (B) on removing the wire, thus showing the moment of aorto-ostial left main stem dissection with no antegrade flow in the left anterior descending artery.
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case_images: Both the LAD artery and D1 branch were wired, and optical coherence tomography-guided PCI was performed to the D1 and LAD lesions without complication (Figure 2A). This test resulted in contrast staining within the aorta, a finding suggesting that there had been an aorto-ostial dissection (Figure 2B, Video 1). Intecc) was also unsuccessful. IVUS was performed over the circumflex wire and demonstrated that the wire was in a false lumen (Figures 3A and 3B, Video 2).
case_images: Intravascular Ultrasound. Imaging demonstrating the intravascular ultrasound catheter (A and B) within the false lumen and (C and D) wiring of the true lumen. Confirmatory intravascular ultrasound was then performed (E and F).
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case_images: Intecc) was also unsuccessful. IVUS was performed over the circumflex wire and demonstrated that the wire was in a false lumen (Figures 3A and 3B, Video 2). On the first attempt, this wire passed into the true lumen, which was demonstrated on IVUS from the false lumen wire (Figures 3C and 3D, Video 3). To confirm the true lumen position of the new Runthrough wire, IVUS pullback was performed on the true lumen wire (Figures 3E and 3F, Video 4).
case_images: Stent Procedure. (A) Demonstrating positioning of the stent with a wire in the aorta, (B) deployment of the stent, (C) return of antegrade flow within the left anterior descending artery but with residual hematoma within the left main stem (LMS), and (D) post-dilatation of the stent. NC = non-compliant.
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case_images: To confirm the true lumen position of the new Runthrough wire, IVUS pullback was performed on the true lumen wire (Figures 3E and 3F, Video 4). To minimize contrast medium injections and propagation of the dissection plane, a second coronary wire was passed into the aorta to mark the position of the left main stem ostium (Figure 4A). A 4.0 x 24 mm biomatrix alpha (Biosensors International) drug-eluting stent was implanted at high pressure (Figure 4B). Angiography revealed that flow had returned within the LAD artery (Figure 4C). The portion within the left main stem was post-dilated with a 6-mm balloon (Figure 4D), with ostial flaring.
case_images: Final Angiography. Imaging in the (A) posteroanterior cranial and (B) posteroanterior caudal views demonstrating antegrade flow in all coronary vessels and some residual dissection in the distal circumflex (seen more clearly in the cranial view).
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case_images: TIMI flow grade 3 and widely patent LAD and circumflex vessels (Figures 5A and 5B, Video 7). The patient was discharged 2 days later without further complication.
case_images: Coronary Angiography and Intravascular Ultrasound. Coronary angiography demonstrating no significant disease in the (A) left anterior descending artery and (B) left circumflex artery. (C) On engagement of the right coronary artery, the catheter caused a spiral dissection. (D) Coronary wire passed into the right coronary artery with intravascular ultrasound (IVUS) performed over the coronary wire. (E and F) Intravascular ultrasound shows the wire and intravascular ultrasound catheter with a large false lumen.
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case_images: We used 5-F diagnostic Judkins left 3.5 (JL3.5) and right 4 (JR4) catheters (Figures 7A to 7F). On testing to check engagement, the catheter tip induced a spiral dissection (Figure 7C, Video 8). This imaging confirmed that the wire was in the false lumen (Figure 7E, Video 9).
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case_images: Electrocardiograms Showing Stuttering ST-Segment Elevation. Electrocardiograms demonstrating transient ST-segment elevation (A) which subsequently spontaneously resolved (B).
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case_images: She presented with chest pain, and serial ECGs demonstrated an aborted ST-segment elevation myocardial infarction (Figure 6).
case_images: Coronary Angiography and Intravascular Ultrasound. Coronary angiography demonstrating no significant disease in the (A) left anterior descending artery and (B) left circumflex artery. (C) On engagement of the right coronary artery, the catheter caused a spiral dissection. (D) Coronary wire passed into the right coronary artery with intravascular ultrasound (IVUS) performed over the coronary wire. (E and F) Intravascular ultrasound shows the wire and intravascular ultrasound catheter with a large false lumen.
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case_images: We used 5-F diagnostic Judkins left 3.5 (JL3.5) and right 4 (JR4) catheters (Figures 7A to 7F). On testing to check engagement, the catheter tip induced a spiral dissection (Figure 7C, Video 8). This imaging confirmed that the wire was in the false lumen (Figure 7E, Video 9).
case_images: Angiography and Intravascular Ultrasound. (A) Second guidewire on angiography in the true lumen (TL) on (B and C) intravascular ultrasound with the original wire in the false lumen (FL).
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case_images: On testing to check engagement, the catheter tip induced a spiral dissection (Figure 7C, Video 8). After repeated attempts, the second wire was eventually spotted within the true lumen (Figures 8A to 8C).
case_images: Cutting Balloon and Stent Treatment. (A to D) Cutting balloon used to dissect the tunica intima to drain the intramural hematoma and facilitate stenting. (E to H) Right coronary artery stented from distal to proximal with overlapping drug-eluting stents.
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case_images: This imaging confirmed that the wire was in the false lumen (Figure 7E, Video 9). A 3.0-mm Wolverine cutting balloon (Boston Scientific) was then used to dissect the tunica intima intentionally to create an outlet for the intramural hematoma and thus facilitate stenting (Figures 9A to 9D). The vessel was then stented in an overlapping fashion from distal to proximal with 3.5 x 38 mm, 4.0 x 38 mm, 4.0 x 38 mm, and 4.0 x 12 mm drug-eluting stents (Figures 9E to 9H).
case_images: Final Angiography. Imaging in the posteroanterior cranial view demonstrating a smooth, unobstructed right coronary artery with no evidence of residual dissection.
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case_images: TIMI flow grade 3 with no angiographic evidence of residual dissection (Figure 10, Video 10), and IVUS demonstrated well apposed and expanded stents with no evidence of residual hematoma. The patient's chest pain resolved, and she was discharged the following day.