Background 

Iatrogenic left main-stem dissection/occlusion (IACD) class F (dissection that progressed to impaired flow or total occlusion) involving the aortic root is the rarest and most life-threatening type of dissection. It usually occurs during transcatheter aortic valve replacement (TAVI) or percutaneous coronary intervention (PCI). It is most associated with hemodynamic instability and every effort must be focused on restoring the coronary flow as quickly as possible, as the final Thrombolysis in Myocardial infarction (TIMI) flow is the only independent predictor of in-hospital mortality.

This report describes a case of IACD resulting from the complications of a primary PCI procedure that was successfully managed by deeply engaged the guide catheter in the false lumen and aspirating about 10 ml of blood in the hope of reducing the false lumen diameter. Then, the left main true lumen was quickly wired from the ascending aorta and successfully stented with non-standered approach achieved. This approach is novelty, time and life saving and not yet described before. A similar technique using microcatheter in intervention of chronic total occlusion is known. 

Case Presentation:
A 75-year-old woman with known hypertension presented with non-ST segment elevation myocardial infarction (NSTEMI). After PCI of the left circumflex (LCX) and first diagonal (D1) coronary arteries, she developed a class F left main coronary artery dissection. Emergency primary left main coronary artery intervention with non-slandered approach was successfully performed. Further hospitalization was uneventful and after 2 weeks, the patient was discharged. Clinical and echocardiographic outcomes were favorable at 3 months and 1 year follow up. 
Conclusion 

IACD is one of the most catastrophic complications during coronary intervention. If this happens, various treatment strategies can be considered according to the hemodynamic status and coronary TIMI flow. In the case described herein, a rapid successful left main percutaneous coronary intervention LM-PCI with non-standard approach was done. 

Rapid successful PCI provides a reasonable time-saving treatment option in this context, as the final TIMI flow is the only independent predictor of in-hospital mortality. 

 
Keywords

Left main coronary artery dissection, Aortic dissection of the left -coronary sinuses of Valsalva, left main coronary artery intervention, Case report