From bad to worse: a case report of bilateral iatrogenic coronary dissection complicated with cardiac arrest.

Background: Iatrogenic coronary artery dissection is a rare but life-threatening complication, occurring in fewer than 0.1% of coronary procedures. It is typically precipitated by aggressive or deep intubation with large catheters. While most dissections are unilateral, bilateral occurrences are exceptionally rare and often suggest underlying 'vulnerable' vessel conditions, such as fibromuscular dysplasia. Case summary: A 40-year-old woman with no medical history presented with non-ST-elevation acute coronary syndrome. Initial angiography of the right coronary artery (RCA) and left main coronary artery (LMCA) showed no obstructive lesions. Post-procedure, the patient developed recurrent chest pain and circumferential ST-segment elevation, followed by ventricular fibrillation that required electrical cardioversion. A second angiogram revealed simultaneous dissections of both the LMCA and RCA. Emergent stenting was successfully performed to seal the dissection planes in both vessels. An extensive autoimmune and systemic vascular workup was negative. The patient recovered well and was discharged four days later. Discussion: LMCA dissections carry a high mortality risk because they jeopardize a vast territory of the myocardium. In this case, the simultaneous involvement of both the RCA and LMCA represents an extreme clinical challenge. Management must be immediate; urgent stenting is the gold standard to prevent total vessel occlusion, myocardial infarction, and irreversible cardiac damage.