ID- 103025

Mr. X 46 years old gentle man, hypertensive, non-diabetic,smoker presented with complaints of exertional central chest pain radiateto inner aspect of the left arm. On examination pulse was 90/minutes. Blood pressure was120/80 mmHg. Oxygen saturation was 98% underroom air. S₁and S₂ were normal. Lung bases were clear. He gave history of Inferior wall ST elevated myocardial infractionand treated with thrombolytic one month back. He was diagnosed as a case of old myocardialInfraction Inferior with post myocardialInfraction angina with hypertension.

Electrocardiogram showed old myocardial infractioninferior.  Echocardiogram showed hypokinetic left ventricular inferiorwall with LVEF 62 %.Haemoglobin was 12.0 mg/dl .Total white cell count was 7,000/cubic ml. Platelet count was 2,00,000 / cubic ml . Serum Troponin I was 0.001 ng/l.HbA1c was6.0%. Serum creatinine was 0.90 mg/dl.Normal chest X ray posterior anterior view.
Figure1 : ECG shows OMI InferiorFigure2 : Echocardiogramshows normal LA , Aorta and LV diameter with LVEF 62 %Figure3 : Echocardiogram shows normal LV cavity diameters with hypokinetic inferior wall

Coronary angiogram through right distal radial artery reveals normal leftmain coronary artery. Left anterior descending artery showed minor plaque inmid part.Left circumflex coronaryartery was non dominant and 30% stenosis in mid OM₁.Right coronaryartery dominant vessel with  99% stenosisin proximal part of posterior descending artery. 
Video 1 : Coronaryangiogram of right coronary artery showed 99% stenosis in proximal part ofposterior descending arteryVideo 2: Coronaryangiogram of the Left coronary artery showed mild lesion in mid partVideo 3 : Nondominant left Circumflex artery with 30% stenosis in mid OM₁
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6F JR 3.5 Medtronic Launcher Coronary Guide Catheter, USA was used.Terumo Runthrough NS Floppy PTCA guide wire 0.014”(0.36mm), Japan crossed thelesion and parked in the distal part of the PDA . Pre dilatation was done with Maverick2 ™PTCA BalloonCatheter, Boston Scientific, USA 2.0 mm X 12mm semi complaint balloon at 8 atm. Resolute Integrity RX Zotarolimus Eluting Coronary 2.25mm X 30 mm stent,Galway, Ireland was deployed in the PAD at 10 atm. During deployment of stentin PDA radiological features of dissection of RCA in proximal and mid part seenwhich is more obvious thereafter. Gradually it extent proximally to ascendingaorta, type A dissection ( Debakey type II ) of aorta and distally to  proximal part of PDA deployed stent. Patientwas haemodynamically compromised. To prevent further extension first deployed Orsiro Sirolimus ElutingCoronary 3.5mm X 40 mm stent, Biotronik AG, Switzerland at 12 atm in ostioproximal and mid part of RCA . Another Orsiro Sirolimus Eluting Coronary 3.0mmX 40 mm stent, Biotronik AG , Switzerland at 12 atm deployed in mid and distalpart of RCA overlapping proximal and distal stent. Upper flap of aorticdissection disappears. Echo cardiogram showed no pericardial effusion or aorticregurgitation. 
Video 4 :  After PDA stenting with ResoluteIntegrity RX Zotarolimus Eluting Coronary 2.25mm X 30 mm stent , dye held up inostium ,  dissection flap in proximalpart and flow compromised in distal part of RCA. Dissection of RCA also extendinto the ascending aorta creating a type A dissection ( Debakey type II ) ofaorta. Video 5  : To prevent furtherextension of dissection in ascending aorta first deployed Orsiro Sirolimus Eluting Coronary 3.5mm X 40 mm stent, BiotronikAG , Switzerland  at 12 atm in ostioproximal and mid part of RCA .Video 6 : After another Orsiro Sirolimus Eluting Coronary, Biotronik AG ,Switzerland ,3.0mm X 40 mm stent deployed in mid and distal part of RCAoverlapping proximal and distal stent  ,patientwas  hemodynamically stable  and angiographically showed no furtherextension of ascending aorta.
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Catheter-induced aorto coronary dissection during Percutaneous CoronaryIntervention is a relatively infrequent, but potentially life-threateningcomplication. Although treatment of ascending aortic dissection may requiresurgical repair, stenting at the origin of the dissection area may besufficient in aorto coronary dissection following Percutaneous CoronaryIntervention. Our patient 64 years hypertensive gentle man presented with oldmyocardial infraction inferior with angina with critical lesion in proximalpart of PDA. During PCI unfortunately simple procedure may turn into morecomplicated scenario involving dissection of whole RCA including ostium andascending aorta creating a type a dissection (Debakey type II) of aorta.  We took attempt to occlude further retrograde extension into ascendingaorta by deploying non covered stent across the ostium. So good control ofretrograde flow was obtained. Rest of the RCA was stented with another stent.Follow up patient with Transthoracic Echocardiography showed no evidence ofaortic regurgitation and healing of dissection.