CathLabHub

CathLabHub complications toolkitcathlabhub.com/toolkit/coronary-dissectionIn review, October 24, 2026

Recognize

The signs on the monitor, the image and the patient.

  • ImageA linear or spiral filling defect, a double lumen or contrast that stays in the wall after the dye clears; NHLBI types A to F, E and F with reduced or no flow 12.
  • ImageStaining that climbs from the ostium into the sinus or the ascending aorta: class I in the cusp, class II up the aorta under 40 mm, class III beyond 40 mm 31.
  • MonitorA damped or ventricularized pressure before the injection, then ST elevation, ventricular arrhythmia or hypotension 2.
  • PatientSudden chest or back pain after a deep engagement or a forceful injection, often with an Amplatz guide in the right coronary 21.
  • EchoNew aortic regurgitation, a flap in the ascending aorta or an effusion when the dissection extends 2.

Act now

In the order the operator does them. The first three come first, whatever else is happening.

  1. Keep the wire in the true lumen; do not pull it to reposition the guide 2.
  2. Stop contrast injections through the engaged guide and disengage gently; inject only nonselectively if you must 2.
  3. Call for help and tell the team the lumen is dissected; support the pressure and treat arrhythmias.
  4. If the wire is lost, rewire with a workhorse wire or a microcatheter and confirm the distal true lumen with IVUS or a contralateral injection, not by injecting through a microcatheter 2.
  5. Stent quickly, proximal dissections and the left main first 2.
  6. Aorto coronary: stent the ostium with the stent protruding 1 to 2 mm into the aorta to seal the entry, guided by IVUS 2.
  7. Intramural hematoma: stent distally first, then proximally; a cutting balloon can decompress it 2.
  8. If the true lumen cannot be regained: dissection and reentry techniques, or emergency surgery for a large vessel such as the left main 2.
  9. Surgery for aortic regurgitation, rupture into the pericardium or extension beyond about 40 mm (class III) 23.

Equipment

From the complications cart. Linked items open in the equipment directory.

Drugs

Adult doses as the cited source gives them. Check your formulary and the label.

  • Intracoronary nitroglycerin100 to 300 mcg, to separate spasm from dissection; avoid in hypotension 42.Product in the directory
  • HeparinKeep the ACT in range while stenting; check it now 2.Weight based dose in the Cath Med App
  • Blood pressure control after an aorto coronary dissectionKeep systolic pressure controlled, as extension is pressure driven 12.

Who to call

The escalation ladder, first call first.

  1. Second operator: now, to hold the wire and guide while you size the stent.
  2. Cardiac surgery: for left main dissection that cannot be wired, class III aortic extension, aortic regurgitation or tamponade 23.
  3. Echo or CT: for the aortic root and an effusion when staining reaches the sinus 2.
  4. Shock team: if the pressure falls with a large territory at risk 2.
  5. Anesthesia: if surgery or a long recovery of the true lumen is likely.

The bailout step by step

Sealing an aorto coronary dissection with an ostial stent 2

  1. Keep the wire across; stop all injections through the engaged guide.
  2. Back the guide out of the ostium onto the wire, coaxial but not engaged.
  3. Confirm the distal true lumen with IVUS.
  4. Size the stent with IVUS to a diameter that will seal the entry.
  5. Position the stent so that it protrudes 1 to 2 mm into the aorta 2.
  6. Deploy, then flare or post dilate the ostium as needed; IVUS to confirm full coverage 2.
  7. Check the result without a forceful injection; if the distal vessel must be seen, inject through a dual lumen microcatheter advanced distally 2.
  8. Large or ascending aorta involvement: serial CT or TEE until it is stable or resolved 2.

Prevent

  • Never inject on a damped or ventricularized pressure; get coaxial first 2.
  • Use anchor techniques before deep seating aggressive guides such as an 8 Fr Amplatz 2.
  • Deliver guide extensions over a balloon and inject through them with care 2.
  • Avoid power injection after the proximal segment of a CTO vessel has been dilated 2.

After care and documentation

  • Systolic pressure control; serial imaging for aortic involvement, and discharge once stable over 24 to 48 hours for classes I and II 12.
  • Do not interrupt antiplatelet therapy after a new stent 1.
  • Document the type or class, the guide used, how it was sealed and the imaging plan.

Practice

Emergency simulator cases in the Cath Trainer app. The link opens Cases; type the case number in the search box.

  • EMG-0017: Pain after a deep engagement and a forceful injection
  • EMG-0019: Back pain with an Amplatz guide in the right coronary
  • EMG-0069: Tearing pain during a guide injection

References

  1. Berg R, Lim MJ. Complications of percutaneous coronary interventions. In: Kern MJ, ed. The Interventional Cardiac Catheterization Handbook. 3rd ed. Saunders, Elsevier; 2013. Chapter 4.
  2. Brilakis ES. Manual of Percutaneous Coronary Interventions. Elsevier; 2021. Chapter 25, Acute vessel closure.
  3. Dunning DW, Kahn JK, Hawkins ET, O'Neill WW. Iatrogenic coronary artery dissections extending into and involving the aortic root. Catheter Cardiovasc Interv 2000;51:387-393.
  4. Brilakis ES. Manual of Percutaneous Coronary Interventions: A Step-by-Step Approach. Academic Press, Elsevier; 2021. Chapter 3, Medications.
  5. CathLabHub Cath Trainer app, emergency simulator: case library (cathlabhub.com/app, Cases).

Educational reference for cath lab teams, not medical advice and not a standard of care. Your local policy, the device instructions for use and current guidelines govern. Verify every dose before use. Printed from cathlabhub.com/toolkit/coronary-dissection. First version, in clinical review: an interventional cardiologist is checking every card before it is final. Every number cites its source on the card.