65 year old male admitted with Inferior wall MI R/F –Non Hypertensive  , Non DiabeticECG –SHOWED Evolved IWMIECHO –showed RWMA+(inferior wall Hypokinetic ) , Mild LV Dysfunction(EF-45%)Hypothyroidism.

ECG –SHOWED IMWI ECHO – showed RWMA+(inferior wall Hypokinetic ),Mild LV dysfunction(EF-45%)

CAG –showed TVD(Triple Vessel Disease)
RCA- Ectatic RCA ,proximal critical 90 % lesion
LAD –PROXIMAL 70%LESION
LCX- MID 80 %LESION

 RCA was engaged  with JR 3.5 , 6 F , when we attempted to cross the wire  workhorse hard wire Proximal RCA got dissected slow flow occurredpatient went into bradycardia and cardiogenic shock  and Inotrops started to stabilize him.
Finally was able to cross the wire through true  lumen bypassing the dissected part of RCA . Attempted to cross 3.5 * 24 mm DES  , but the stent could not cross the lesion  and the whole symmetry got out and the catheter got disengaged. Trying to  re engage the JR catheter , the ostioproximal RCA got dissected and there was slow flow in RCA,       patient went into Complete Heart Block , temporary Pacemaker was Inserted. ,       Patient developed Re infarct with ECG showing  fresh ST elevation  in Inferior leads, developed Shock and inotrops accelerated.Final shoot showed complete dissection from ostial RCA to mid RCA with slow flowJR guiding catheter reengaged , wire was able to pass through the true lumen  Shoot showed well flowing RCA with complete ostioproximal to mid diffuse  dissectionGuide liner used  to cross the lesion and as a support to cross  4 * 24 DES stent across the lesion to coverup dissection upto RCA  ostium And expanded upto 12 ATM with 2 struts    hanging into the Aorta .Post implantation , TIMI III flow was achieved and the result was excellent .Patient vitals got stabilized post Procedure ,Temporary pacemaker removed after Stabilization.

Proper shoot in  all  angles is must for the assessment of lesion and tortuosity of vessel.  Right selection of  PTCA Guide wire preferably soft wire should be used To avoid dissection.Temporary Pacemaker  should be placed before starting angioplasty procedure.Use  of extra support like buddy wire or Guide liner is a must during stent implantation in torturous lesions. Cardiothoracic Surgery  backup is a must in such cases.