1. Complex PCI to CTO lesion in RCA with nightmares complications
Ahmed Mostafa Nada

2. INTRODUCTION
Although rare,iatrogenic coronary artery dissections are well known complications in the era of interventional cardiology , especially with the advances in technology, devices, and operator experience that have led to the performance of more complex percutaneous interventions.
Management of the dissection propagating to the ascending aorta is challenging.
Sometimes, it’s difficult to discern between coronary perforation and dissection, but unnoticed minimal pericardial effusion may be an important clue.
Rapid recognition is essential to employ potentially life saving management techniques in a timely manner.

3. Case Report
A 55-years-old man , smoker (with no other coronary risk factors) ,presented with effort chest tightness for 6 months duration, which increased in severity and frequency over the last week before presentation , he was admitted to our hospital as a case of (ACS)unstable angina .
Lab. results including cardiac enzymes were normal.
ECG was normal, echo revealed EF of 50% with no SWMA.
The coronary angiography revealed three vessels CAD ; a CTO lesion in proximal RCA (with retrograde collaterals seen from the left system) and another LCX and OM lesions(small vessels). (Fig. 1,2)

4. Coronary angiogram revealed a CTO lesion in proximal RCA with retrograde filling from the left system

5. PCI to right coronary artery (RCA) , we used a 6Fr Hockey-stick (HSII) guiding catheter via the right femoral artery (superior take-off RCA).
Lesion crossed with intermediate wire ,at this moment, the angiogram showed severe spiral dissection involving osteal RCA and the wall of aortic root with ?distal coronary rupture (?Ellis type III B)- wire advanced only to mid RCA - at that time patient was asymptomatic, hemodynamically stable without ECG changes.(Fig. 3,4,5)
Bedside echocardiography revealed no pericardial effusion.
Wire advanced to distal RCA without any resistance then ballooning and stenting to proximal and mid RCA was done successfully with 2 drug-eluting stents( 3.5×26 in mid RCA and 3.5×38 in osteal and proximal RCA) with post-stent dilatation.(Fig. 6,7,8)
Patient was shifted to CCU with follow up echo (after 12 and 24 hours) which were free from pericardial effusion.
He was discharged in the next day ( completely asymptomatic and stable) and he was scheduled for coronary angiogram after 2 months (follow up and PTCA to the other diseased vessels) .

6. Aorto-osteal dissection ,coronary spiral dissection and
Aorto-osteal dissection ,coronary spiral dissection and ? Coronary rupture just after crossing the lesion(wire stopped at mid RCA)

7. Successful stenting to proximal and mid RCA ,with no residual extravasation flow could be seen in distal RCA after conventional stenting

8. After 2 months Patient is completely asymptomatic and follow up angiogram revealed sealing of aorto-coronary dissection and widely patent deployed stent. (Fig. 9,10)

9. Take-home messages
Aortocoronary dissection or perforation during PCI is a rare but life-threatening complication.
Careful selection and manipulation of catheters and paying more attention to high-risk patients are important to avoid these complications.
Detailed review of the angiograms when complications occur is mandatory.
Prompt treatment with conventional stenting for coronary dissection is essential and lifesaving, but may be harmful for coronary perforation.
There are no evidence-based guidelines to assist the operator in treating catheter-induced aorto-coronary dissection or perforation.
Only a very small percentage of aortocoronary dissection like these would be sealed off spontaneously.