Severe Dissection of the Right Coronary Sinus of Valsalva and Ascending Aorta During PCI for ACS

A 73-year-old male patient with history of hypertension and tobacco use presented to the emergency department after a syncopal episode. Syncope was preceded by chest pain, nausea, and cutaneous pallor approximately 24 hours prior to presentation. Initial electrocardiogram showed sinus rhythm, with ST-segment depression in V2 to V6, II, III and aVF. Initial cardiac troponin I and CK-MB were moderately elevated.

The patient was hemodynamically stable in Killip class 1. Symptoms improved after administration of aspirin, ticagrelor, enoxaparin, and intravenous nitroglycerin.

Transthoracic echocardiography was significant for left ventricular ejection fraction of 59%, hypokinesis of the basal segment of the inferior wall, and mild dilatation of the ascending aorta. Diagnostic cardiac catheterization showed severe stenoses in the proximal, middle, and distal right coronary artery (RCA) (Video 1). Nonobstructive lesions were seen in the left anterior descending and left circumflex arteries (Videos 2-3). Engagement of the right coronary ostium was challenging due extreme tortuosity in the iliac arteries. After the last RCA injection, TIMI 0 flow was noted (Video 4). The patient remained stable, without chest pain or neurological symptoms.

Video 1

Video 2

Video 3

Video 4

Considering this complication, what would be the best approach?

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