Case Presentation
The first case is a 65-year-old Caucasian female with a past clinical
history of non-ST elevation myocardial infarction (NSTEMI), who was
referred to our Center for a new onset of inferior ST-elevation
myocardial infarction (STEMI). She was promptly undergone percutaneous
transluminal coronary angioplasty (PTCA) with implantation of four drug
eluting stents (DES).
During the procedure a dissection of the right coronary artery (RCA)
with the subsequent formation of an aortic wall hematoma was detected;
it promptly extended in a retrograde fashion from the right sinus of
Valsalva up to the ascending aorta (Figure 1 ). An
attempt to occlude the intimal entry orifice was made by delivering a
right ostial stent but unfortunately the dissection progressed towards
the aortic arch so an emergent surgery was planned. We performed with a
femoro-femoral institution of cardio pulmonary bypass (CBP) an ascending
aorta replacement with a straight Dacron tube #28 and a single coronary
artery bypass (CABG) on the right coronary artery (RCA) with a single
tract of autologous saphenous vein.
Since the weaning from CPB was unachievable due to hemodynamic
instability, an Extra Corporeal Membrane Oxygenation (ECMO) implantation
was necessary. [2]
The patient was successfully weaned from the ECMO after 4 days in the
Intensive Care Unit (ICU). The post-operative course was favorable and
the patient was later transferred to a rehabilitation Center.
The second case is a 66-year-old male with a history of STEMI and out of
hospital cardiac arrest treated with PTCA + DES on left coronary artery
(LCA), complicated by the dissection of LAD itself treated with a stent
re-apposition. During the following years he was subjected to multiple
PTCA and DES procedures for intra-stent restenosis and ongoing severe
lesions on the right coronary artery.
During the last procedure of stent deployment the patient developed a
dissection of the proximal part of the RCA that rapidly extended upward
until ascending aorta (Figure 2 ). An emergent computed
tomography (CT) scan showed the progression of the dissection to the
innominate and the left common carotid artery. He finally underwent
emergency ascending aorta replacement surgery with a #24 Dacron tube
prosthesis. The postoperative course was characterized by a minor stroke
on the right parietal territory with no clinical remarks at the
discharge on 7th postoperative day.
The last case is a 78-year-old male patient with a history of double
emergent CABG for severe instable main trunk-related chest pain. During
the transcatheter complementary revascularization occurred nearly 4
months after the surgery an intimal flap of the inner aortic wall near
the right coronary ostium was detected after the injection of contrast
medium. The CT scan showed an aortic dissection from the right coronary
ostium to the proximal saphenous vein graft anastomosis. The patient
underwent an emergency redo surgery (Figure 3 ) with
replacement of ascending aorta with a #28 straight Dacron prosthesis
via a femoro-femoral cannulation; the saphenous vein graft was finally
anastomosed to the marginal branch of the circumflex artery. The patient
required the intra-aortic balloon pump (IABP) to be weaned from the CBP
and was finally discharged to a rehabilitation center on
11th postoperative day.