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A 44 year old woman presented with an eight month history of recurrent exertional chest and back pain. A diagnosis of Marfan syndrome had been made in 1985; in 1988, following the discovery of a chronic type A dissection, she underwent a Starr Edwards aortic valve and ascending aortic replacement with reimplantation of the coronary arteries.
On this presentation magnetic resonance scanning showed a dissection flap extending across the aortic arch that had been present and stable for 13 years. Myocardial perfusion scanning demonstrated a reduction in tracer uptake in the inferior wall. Coronary angiography revealed a spontaneous distal right coronary artery (RCA) dissection in a tortuous vessel (panel A, black arrow). The RCA was cannulated using a 6 French Judkins right guide catheter and two guide wires. Direct stenting of the lesion was performed uneventfully with a 3.5 × 23 Sonic stent (Cordis) (panel B, white arrow). Following the procedure the patient remains well.