Intravascular ultrasound-guided treatment for simultaneous ostial left main intramural hematoma and anomalous right aortocoronary dissection.

The prevalence of iatrogenic catheter-induced ostial coronary artery dissection is very low (0.09%) (1). The incidence of coronary anomalies (total) is 5.64% and ectopic right coronary artery (RCA) (left cuspid) is also rare (0.92%) (2). To the best of our knowledge, this is the first case report of a simultaneous iatrogenic catheter-induced ostial RCA dissection and propagation to the ostial left main (LM) coronary artery by intramural hematoma (IMH). We report a case of a 61-year-old male with underlying disease of type 2 diabetes mellitus and hypertension under regular medication control. He had experienced intermittent chest pain for more than 3 months. He came to our hospital after suffering acute RCA occlusion with cardiogenic shock without management while receiving diagnostic catheterization in another hospital. To perform the initial diagnostic, we used a 6 French Ikari Left 4 (Terumo, Japan) guiding catheter and changed to a 6 French SAL1 (Medtronic, U.S.A.) guiding catheter to determine the origin of the RCA anomaly in the left coronary cuspid. Initially, ostial dissection with intramural hemorrhage at the RCA without flow compromised with the acknowledgement of LM propagation (Panel A) (Video 1). Ostial RCA was managed directly with a Xience Sierra stent (3.5 × 23 mm; Abbott, U.S.A) to seal the entry of dissection, followed by NC emerge 3.5 × 15 mm balloon (Boston, U.S.A.) inflated up to 24 atmosphere (atm). Intravascular ultrasound (IVUS) confirmed that the stent fully covered the entry point of the ostial RCA (Panel B). The left main (Panel C) was then managed by IVUS-guided (Boston iLAB Opticross, U.S.A.) cutting balloon (Wolverine 4.0 × 6 mm; Boston, U.S.A.) inflated at up to 12 atm to fenestrate the IMH (Panel D; Video 2) at the LM level, followed by the implantation of a bailout stenting Xience Sierra (4.0 × 18 mm; Abbott, U.S.A) and by NC emerge 5.0 × 15 mm balloon (Boston, U.S.A.) inflated up to 18 atm. Post procedure angiogram and IVUS confirmed the effectiveness of the intervention. (Panel E, F). In this case, due to the origin of the RCA anomaly, the dissection and IMH immediately propagated to the LM. Fortunately, the patient was hemodynamically stable. We chose to use the cutting balloon and IVUS-guided intervention strategy, which resulted in the remission of the patient's condition.