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An 85 year old man first presented with non-ST elevated myocardial infarction. He had refractory ischaemic symptoms. A coronary angiogram done six days after admission showed three vessel disease. Initial balloon angioplasty performed on the culprit proximal left anterior descending artery (LAD) lesion resulted in a type B coronary dissection. Stenting (3.0 mm/16 mm NIR SOX, Boston Scientific) was then performed. There was distal extension of the dissection, which was covered by a second stent (3.0 mm/12 mm S670D AVE, Medtronic), with slight overlap between the two stents. The angiographic result was satisfactory, and the patient was stabilised. He later declined second stage angioplasty to other vessels and was discharged. Two months later, he developed acute chest pain and pulmonary oedema. The ECG showed a deep ST depression over all precordial leads. A coronary angiogram was performed, which revealed a ruptured LAD with wide separation of the conjoint ends of the two stents (left panel) and a large coronary pseudoaneurysm (middle panel). On echocardiography (right panel), the large coronary pseudoaneurysm appeared as a well circumscribed cavity in the left anterior aspect of the aortic root and basal anterior region of the left ventricle (LV). Flow into the pseudoaneurysm was demonstrated by colour Doppler. Echocardiography also showed dyskinesia in the anteroseptal and anterior regions (arrowheads), which might have stretched the overlying epicardial coronary artery and ultimately caused the LAD artery rupture at a weak point between the two stents. An attempt was made to deploy a cover stent but a guidewire could not be passed through the pseudoaneurysm down to the distal LAD. In view of the patient’s age and other medical co-morbidities, surgery was not contemplated. The patient continued to have refractory heart failure and died four days later.
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