The most common cause of acute myocardial ischemia following percutaneous transluminal coronary angioplasty is coronary dissection, which characteristically remains localized to the site of balloon dilation. In this article, however, we report on 4 patients in whom percutaneous transluminal coronary angioplasty was complicated by coronary artery dissection extending distally beyond the site of anticipated vein graft anastomosis. Intraoperative diagnosis of distal coronary dissection is suggested by a characteristic appearance of the artery and confirmed by the finding of true and false lumens at the time of coronary arteriotomy. Successful revascularization is achieved by anastomosis of a vein graft to the true lumen with reapproximation of the dissected arterial layers. Proximal coronary artery ligation in this setting is unnecessary.