Iatrogenic coronary artery dissection: detection, management, and prevention

Percutaneous coronary intervention (PCI) has become a cornerstone treatment for symptomatic coronary artery disease. Although generally safe and effective, PCI may still lead to serious complications such as coronary artery dissection or vessel perforation. Coronary artery dissection can arise spontaneously or be triggered by catheter-based procedures, the latter referred to as iatrogenic coronary artery dissection (ICAD). ICAD, while uncommon, carries significant procedural and prognostic implications; catheter-induced ostial dissection has been reported in approximately 0.09% of coronary angiographic procedures, while 30-day mortality reached 20.8% in a high-risk surgical cohort of patients with PCI-related coronary injuries. Given the increasing use of coronary interventions and the complexity of contemporary lesions, early recognition and accurate characterization of ICAD have become critical. Advances in intravascular imaging-particularly intravascular ultrasound and optical coherence tomography-have improved the ability to identify dissection morphology, understand underlying mechanisms, and guide real-time management. Furthermore, accumulating evidence highlights the role of patient characteristics, lesion anatomy, catheter/device interactions, and procedural techniques in shaping ICAD risk. This narrative review integrates current knowledge on the classification, imaging features, risk determinants, management strategies, and prevention of ICAD, providing a structured framework to support safer and more precise coronary intervention.