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A 73 year old man with known coronary artery disease and acute coronary syndrome was referred for coronary angiography. ST element elevation occurred during contrast injection into the right coronary artery (RCA). Furthermore, contrast staining was detected close to the RCA ostium (below, left panel). Transoesophageal echocardiography (TOE) showed a focal dissection of the ascending aorta (below, middle panel). The patient was immediately referred for computed tomographic (CT) coronary angiography. The CT examination was performed using a 16 row multislice CT (Somatom Sensation 16, Siemens, Forchheim, Germany). Iodinated contrast (Xenetix 300, Guerbert GmbH, Sulzbach, Germany), 100 ml, was continuously injected into an antecubital vein. The CT scan showed an intramural contrast depot and a focal dissection of the ascending aorta compressing the ostium of the right coronary artery (below, right panel). A coronary bypass operation was performed immediately. Two weeks later a follow up CT examination was performed which showed a patent venous bypass graft to the proximal RCA.