Aortic Dissection During Diagnostic Coronary Angiography in a Patient With Acute Coronary Syndrome: The Role of Off-Pump Coronary Artery Bypass Grafting

Abstract

Iatrogenic aortic dissection (IAD) is an extremely rare complication of coronary angiography, most often occurring during percutaneous coronary intervention (PCI) and typically resulting from retrograde extension of a coronary artery dissection. The coexistence of IAD with acute coronary syndrome (ACS) presents significant management challenges, with no established guidelines to guide therapy. Management decisions are influenced by several factors, including whether angiography is performed in the setting of stable angina versus ACS, the extent of ischemic myocardium at risk, the patient’s hemodynamic stability, and the extent of aortic involvement - particularly whether the dissection is confined to the aortic root or extends into the ascending aorta by less than or greater than 4 cm. Treatment strategies may include PCI alone for the coronary dissection or urgent surgical repair of the aorta with coronary artery bypass grafting (CABG). The role of off-pump CABG in this context remains poorly defined. We describe a unique case of a patient with severe mid-left anterior descending (LAD) artery disease presenting with a non-ST elevation myocardial infarction (NSTEMI), who developed a type II IAD during diagnostic coronary angiography without associated coronary artery dissection. Prompt recognition, careful imaging with transesophageal echocardiography (TEE) and computed tomography angiography (CTA), and immediate medical stabilization prevented progression of the dissection. This allowed for a successful and uncomplicated off-pump left internal mammary artery (LIMA) CABG to the LAD, resulting in excellent short- and long-term clinical outcomes.