MNM

A 77-years-old Indian lady with long standing hypertension, dyslipidaemia and coronary artery bypass surgery in 2010 (LIMA-LAD, SVG-LADD1, SVG-OM and SVG-PDA), experienced recurrent angina. Her body mass index was 24.7 kg/m². In 2013 her graft study revealed severe disease of all native arteries, patent SVG-LADD1, SVG-OM & SVG-PDA. During the study, noted left subclavian stenosis with spontaneous dissection flap. Procedure was abandoned and LIMA-LAD was not assessed.
Video 1. SVG-LADD1.mov
Video 2. SVG-OM.mov
Video 3. SVG-PDA.mov

CTA showed moderate left subclavian artery stenosis with small, rudimentary LIMA. TTE showed ejection fraction 48%. She presented back in 2019 with acute coronary syndrome. Repeat graft study showed 50% stenosis in distal LM, 70% stenosis with calcified proximal to mid LAD, 80% stenosis in LCx and CTO in proximal RCA. All saphenous grafts remain patent. 70% stenosis in the proximal left subclavian seen with pullback gradient of 52 mmHg. She was planned for PCI LAD to left main with rotablator.
Video 4. LM-LAD.mov
Video 5. LCx.mov
Video 6. RCA.mov

Right femoral artery secured with 7Fr sheath. EBU3.5 7Fr guide catheter used. Upon engagement, noted staining at osteoaortic junction during injection. Patient had chest pain and blood pressure dropped. TTE showed no pericardial effusion. Difficulty in wiring of Runthrough to LAD, however wire kept going to LCx easily. Runthrough wire left in LCx. Sion Blue wire used to wire the LAD. Proximal to ostial LAD was predilated with Apollo 3.0x10 mm and stented with Orsiro 3.0x35 mm stent.
Video 7. AORTIC OSTIAL JUNCTION DISSECTION.mov
Video 8. ORSIRO 3.0X35.mov
Video 9. XLIMUS 3.5X24.mov

Another Xlimus 3.5 x 24 mm stent was overlapped and stented till ostial left main. Once the dissection flap secured, predilatation with Sapphire II 2.0 x 15 mm at the mid LAD was done. Another Xlimus 2.5 x 28 mm stent was overlapped, stented and all postdilation was done. Ostium and the left main artery was postdilated with Pantera LEO 3.75 x 12 mm. The final result showed good brisk flow down LAD from the ostial left main with minimal staining remaining at the ostium of the left main artery. After a month, a repeat coronary angiogram to the left coronary artery showed TIMI 3 flow down and with no more staining at the ostial left main.
Video 10. POST 1ST & 2ND STENT.mov
Video 11. XLIMUS 2.5X28.mov
Video 12. FINAL RESULT.mov
Video 13. 1 MONTH POST PCI.mov

A catheter-induced aortic root dissection can be catastrophic if not recognized and dealt with immediately. Preexisting atherosclerotic plaque with heavy calcification requiring aggressive catheter manipulation and the use of large size guiding coronary catheter, especially in a small build lady are among factors underlying the occurrence of coronary dissection. In our case, our patient had a Dunning class I dissection of the osteoaortic junction and was successfully bailed out.