a 38-year - old woman was admitted to our outpatient clinic with accelerating back pain and fatigue following a kick to her back by her husband two days previously . on her physical examination , an ecchymotic area on her back between the scapulae was observed . she had pallor , her blood pressure was 80/60 mmhg in both arms , and was tachycardic on auscultation . st segment elevations were observed in the d1 , avl , and v2 leads , along with accelerated idioventricular rhythm ( fig . 1 ) . transthoracic echocardiography demonstrated akinesia of the anterior septal , apical , basal - mid septal , and basal - mid anterior walls , and her ejection fraction was 20% . we detected a dissection of the left main artery , the left anterior descending artery ( lad ) , and the circumflex artery , originating from the middle portion of the left main coronary artery ( lmca ) ( figs . 2 and 3 , supplemental videos 1 , 2 ) . a saphenous vein was grafted to the distal lad . during the intraoperative evaluation of the epicardial vessels , our team of cardiac surgeons did not plan to place a bypass graft to the circumflex artery because it was thin and non - dominant . since the patient was hypotensive under noradrenaline and dopamine infusions , she was transferred to the cardiovascular surgery intensive care unit on an extracorporeal membrane oxygenator ( ecmo ) and intra - aortic balloon pump ( iabp ) . during follow - up , her blood pressure remained low , at approximately 60/40 mmhg , despite aggressive inotropic and mechanical support . on the second postoperative day , although the patient s lad artery had been revascularized by a saphenous vein graft , her left ventricular ejection fraction remained as low as 10%15% , leading to ventricular failure . asystole and cardiovascular arrest then quickly developed , and despite aggressive cardiopulmonary resuscitation , she died . coronary artery dissection after blunt chest trauma is an extremely rare condition that can be fatal , and some cases are detected in postmortem examinations . left main coronary artery dissection is even rarer . multiple mechanisms exist leading to coronary artery dissection , including intimal tears due to a deceleration injury , compression of the artery between the heart and sternum , coronary spasm , and impairment of the coronary flow by a dissection flap or a superimposed thrombosis . coronary artery dissection is detected most commonly in the lad ( 76% ) , the right coronary artery ( 12% ) , and the circumflex artery ( 6% ) [ 4 , 5 ] . in necropsy series , the most common cause of acquired non - atherosclerotic coronary artery disease is spontaneous coronary artery dissection , and the lad is the artery in which this condition is most commonly detected . the risk factors for spontaneous coronary artery dissection are exercise , arteriosclerosis , cardiovascular disease , oral contraceptive use , marfan syndrome , systemic lupus erythematosis , and connective tissue disorders . however , the time from injury to coronary artery occlusion may vary , ranging from immediately after the trauma to five weeks later . bedside electrocardiography ( ecg ) provides important clues about coronary artery dissection after blunt anterior chest and back trauma . it has been previously reported that patients with baseline ecg changes   on admission should be monitored for 24 hours . the ecg may be normal on presentation , but was found to demonstrate st abnormalities in 63% of patients who are admitted for blunt thoracic trauma within 24 hours of observation . our patient presented with st segment elevation the in d1 , avl , and v2 leads , along with accelerated idioventricular rhythm . some emergency therapeutic options exist for patients with spontaneous coronary artery dissection . in some previous case reports , the patients were managed by primary percutaneous coronary angioplasty , especially patients without lmca lesions . however , surgical treatment remains most common treatment and is associated with the best outcomes . an internal mammary artery graft was not utilized in our patient , because she was in cardiogenic shock , and the surgical team tried to save time by using a saphenous vein graft . in order to prevent death , all available measures were used by our surgical team , including intravenous inotropic agents , iabp , and ecmo . nevertheless , using the internal mammary artery for revascularization may have been more effective for restoring left ventricular function . additionally , complete revascularization , including the circumflex artery , spontaneous coronary artery dissection is a rare and potentially fatal complication of blunt chest trauma in younger patients , and early diagnosis and prompt treatment can be life - saving . physicians should be aware of this possibility when evaluating patients in emergency conditions after blunt trauma of any kind . the 12-lead ecg , cardiac bio - markers , and transthoracic echocardiography , along with other imaging modalities , are important in the management of suspected coronary artery dissection in trauma patients .
we present the case of a 38-year - old woman admitted to our outpatient clinic with accelerating back pain and fatigue following a kick to her back by her husband . upon arrival , we detected st segment elevation in the d1 , avl , and v2 leads and accelerated idioventricular rhythm . 
 she had pallor and hypotension consistent with cardiogenic shock . 
 we immediately performed coronary angiography and found a long dissection starting from the mid - left main coronary artery and progressing into the mid - left anterior descending ( lad ) and circumflex arteries . 
 she was then transferred to the operating room for surgery . 
 a saphenous vein was grafted to the distal lad . 
 since the patient was hypotensive under noradrenaline and dopamine infusions , she was transferred to the cardiovascular surgery intensive care unit on an extracorporeal membrane oxygenator and intra - aortic balloon pump . during follow - up , 
 her blood pressure remained low , at approximately 60/40 mmhg , despite aggressive inotropic and mechanical support . on the second postoperative day , asystole and cardiovascular arrest quickly developed , and despite aggressive cardiopulmonary resuscitation , she died .