Intravascular ultrasound system-guided bail-out stent implantation for iatrogenic aortocoronary dissection: a case report

BACKGROUND: Iatrogenic aortocoronary dissection (ACD) is a rare but potentially devastating complication of cardiac catheterization. We describe a case of an iatrogenic ACD following catheter engagement and balloon inflation of the proximal right coronary artery (RCA) during an elective percutaneous coronary intervention (PCI). CASE SUMMARY: An 81-year-old woman presented with an acute inferior wall ST-elevation myocardial infarction. Emergent coronary angiography revealed the three-vessel diseases. Primary PCI for the culprit lesion of the occluded mid-circumflex artery was successfully performed. After 10 days, an elective PCI for the residual RCA lesions was performed. After the balloon inflation of the proximal RCA, iatrogenic ACD was detected. Intravascular ultrasound-guided stent implantation sealing an entry tear prevented further dissection. The post-operative course was uneventful, and the patient was discharged 1 week later. Follow-up cardiac computed tomography revealed a disappearance of the aortocoronary intramural haematoma. DISCUSSION: This case emphasizes the importance of prompt detection and intervention for iatrogenic ACD. Heart team discussion is essential to determine whether cardiovascular surgery or percutaneous management should be performed. Bail-out stent implantation sealing an entry tear is frequently used and effective, and an intravascular ultrasound system would help to recognize the morphology of ACD, contributing to the safe procedure.