Threading the needle: a case report of double-wiring technique and double intracoronary imaging guidance for a multifenestrated iatrogenic coronary artery dissection

BACKGROUND: Iatrogenic coronary artery dissection (ICAD) may represent a serious complication of percutaneous coronary intervention. Stenting the dissected segment is recommended in large dissections with compromised distal blood flow, although wiring the true lumen is often difficult. CASE SUMMARY: A 64-year-old woman with effort angina was submitted to invasive coronary angiography that revealed a severe stenosis in the distal right coronary artery. A large spiral ICAD occurred after pre-dilatation and guidewire position is lost. We report the treatment of this multifenestrated dissection using combined intracoronary imaging guidance with angiographic co-registered optical coherence tomography and real-time intravascular ultrasound, which were crucial to achieve a successful outcome. DISCUSSION: A double-wiring technique with double intracoronary imaging guidance enables a comprehensive depiction of the compromised artery and should be considered in selected cases to guide true lumen wiring and stent implantation.