fig1: The right coronary arteriography in the 60° left anterior oblique position.

Mentions: A 79-year-old woman was admitted for acute coronary syndrome. In coronary angiography, the left main coronary artery was normal. There were 50% stenosis in the first diagonal branch of left anterior descending coronary artery, 40% stenosis after first diagonal branch, and 80% stenosis after second diagonal branch in the left anterior descending coronary artery. There were 90% stenosis after first obtuse marginal branch and 95% stenosis after third obtuse marginal branch of left circumflex coronary artery. There were 90% stenosis before right ventricular branch, 80% stenosis after right ventricular branch, and 60% stenosis in posterolateral branch of right coronary artery. First, we decided on percutaneous coronary intervention (PCI) for right coronary artery because it was mainly responsible for the patient’s complaint (Figure 1). We crossed the two occlusions with a 0.014 floppy guidewire (Choice, Boston Scientific USA), then we dilated the lesion before right ventricular branch of right coronary artery with a 2.0 × 20 mm viva balloon, (Scimed, Boston Scientific, Ireland) at 16 atmospheres 30 sec. Then, we implant a 3.5 × 23 mm (Meo:DrugStar, paclitaxel eluting stent, Germany) at 10 atmospheres. We decided to direct stent implantation for the second lesion. During the coronary stent implantation, the coronary stent system pushed the guiding catheter into the aorta, while passing to right coronary artery from guiding catheter. We implanted a 3.0 × 23 mm (Meo:DrugStar, paclitaxel eluting stent, Germany) at 16 atmospheres. At the end of the procedure, we noticed an aortic dissection in the proximal of the aorta (DeBakey type II, Stanford type A), while giving the dye for control angiography of right coronary artery (Figure 2). We finished the PCI procedure. Because of hemodynamic stability, we decided to follow the aortic dissection medically, so we took the patient to the coronary care unit. Amlodipine 5 mg/day, gliclazide MR 30 mg/day, metaprolol 25 mg/day, enteric-coated aspirine 100 mg/day, and clopidogrel 75 mg/day were given to the patient. The next day, her echocardiographic examination showed increased echogenity in the proximal part of aorta. One week later, the echogenity in the same part was smaller, and one month later, the echogenity was absent in the proximal part of aorta.

Uyan C, Arinc H, Gunduz H, Akdemir R - Vasc Health Risk Manag (2008)

Bottom Line: A 79-year-old woman with acute aortic dissection due to percutaneous coronary intervention was presented.Aortic dissection is an uncommon but potentially lethal illness that can present in an occult manner making the initial diagnosis difficult.Aggressive medical management is mandatory, as well as urgent diagnostic testing and cardiothoracic consultation.

Affiliation: Abant izzet Baysal University, izzet Baysal Medical Faculty, Cardiology Department, 14280 Golkoy, Bolu, Turkey. cihangirayten@superonline.com

Abstract: Acute aortic dissection is a medical emergency with high morbidity and mortality requiring emergent diagnosis and therapy. A 79-year-old woman with acute aortic dissection due to percutaneous coronary intervention was presented. Aortic dissection is an uncommon but potentially lethal illness that can present in an occult manner making the initial diagnosis difficult. Aggressive medical management is mandatory, as well as urgent diagnostic testing and cardiothoracic consultation.