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.