CASE PRESENTATION 
A 59-year-old female smoker with a history of hyperlipidemia was admitted for ST-segment elevation myocardial infarction (STEMI) in a peripheral hospital. Transthoracic echocardiography (TTE) revealed hypokinesis of the lateral wall, however systolic function was preserved (left ventricular ejection fraction (LVEF) 55%).
She was immediately transferred to the catheterization laboratory, where coronary angiography revealed type II spontaneous coronary artery dissection (SCAD) of the left coronary system, initiating from the distal part of the left main coronary artery (LMCA) (Figure 1A B,). Initially stenting of the ramus intermedius was performed. During stenting manipulations of the first diagonal and left anterior descending (LAD) artery, the dissection extended retrogradely into the LM and left coronary sinus (Figure2A). An additional stent was therefore inserted to the LMCA until its ostium. Specifically, a 3.5mm x 26mm stent followed by overdistension with a noncompliant balloon 4mm x 2mm was introduced into the LMCA, with partial protrusion of its foci into the aortic lumen. Because of the unimpeded flow in the circumflex coronary artery, the dissection was left unhandled. No apparent residual stenosis was seen after the procedure (Figure 2B).
The following day, transthoracic echocardiography (TTE) identified a notable pericardial effusion leading to prompt pericardiocentesis, which evacuated 540cc of bloody content. An urgent CT angiography revealed an aortic intramural hematoma <1cm in size extending longitudinally along the anterolateral side of the ascending aorta, from the aortic root up to the origin of the innominate artery (DeBakey type II). The aorta was 44-45mm in diameter.
Despite attempts to manage this conservatively with strict blood pressure control on the coronary care unit, a repeat CT scan 12 days later revealed expansion of the intramural aortic hematoma, and residual pericardial effusion (Figure 3). Repeat TTE revealed worsening LV systolic dysfunction (LVEF 40%) and hypokinesis of the lateral and anterior-apical cardiac walls, suggesting compromised flow in the left coronary system. The patient was escalated and transferred to the cardiothoracic centre for definitive management.