Type A aortic dissection with coronary involvement presenting as ST-segment elevation: A stepwise approach from bedside to cath lab to prevent catastrophic complications

Acute type A aortic dissection (TAAD) involving the coronary arteries can closely mimic ST-elevation myocardial infarction (STEMI), complicating early diagnosis and management. We report the case of a 35-year-old male presenting with acute chest pain and electrocardiographic findings consistent with STEMI. During cardiac catheterization, extreme difficulty was encountered in coronary engagement. Subsequent aortography revealed a large oscillating intimal flap with collapse of the true lumen, consistent with TAAD. Computed tomography angiography confirmed extensive dissection extending to the iliac arteries. The patient underwent emergent surgical repair; however, the procedure was complicated by massive thoracic bleeding and refractory coagulopathy, resulting in intraoperative death. This case highlights not only the diagnostic challenge of differentiating TAAD accompanied by coronary occlusion from primary coronary occlusion but also introduces a clinically actionable, stepwise diagnostic approach integrating bedside clinical assessment, focused physical examination, laboratory evaluation (D-dimer), imaging (especially echocardiography and CT-angiography), and angiographic recognition. Familiarity with angiographic clues and prompt diagnostic reassessment are essential to avoid catastrophic outcomes.