Alternative treatment methods for spontaneous coronary artery dissection

To the Editor,

We have read the paper by Çimci et al. (1) with great interest. The authors presented a coronary artery dissection case treated using stent implantation in the mid-segment of the left anterior descending artery (LAD), which spread to the proximal segment (1). The dissection did not reach the left main coronary artery. According to the classification by Saw et al. (2), dissection was suitable for type 2A coronary artery dissection, and there was thrombolysis in myocardial infarction-1 flow. The first wire could not be advanced to the LAD. However, with the support of a microcatheter and olive tipped wire, wiring of the distal true lumen was achieved and confirmed. The stent was implanted in the mid-segment, but the intramural hematoma was spread to the proximal segment of LAD. In Video 1, the intramural hematoma advanced through the first diagonal artery, demonstrating the involvement of the proximal LAD by dissection. First, when spontaneous coronary artery dissection (SCAD) is required, the stent should be implanted at a distance of 5 mm to a proximal lesion. A decision should be made according to the distal lesion because, without lesion covering, dissection tends to be advanced in the proximal segment (3). In a case where it is not possible to cover the entire lesion by stent implantation, cutting balloon angioplasty with or without stenting may be considered. The balloon size should be at least 0.5 smaller than the caliber of the vessel being intervened. In particular, short cutting balloons of either 6 or 10 mm sizes with low inflation of 4 atm should be considered (3, 4). Second, because of the propagation of SCAD to the diagonal artery, a cutting balloon with or without stenting may be chosen as the primary treatment strategy, especially in the proximal part of the coronary arteries, such as the ostial LAD or circumflex artery SCAD. Third, if resources are limited in the catheter laboratory, plain ballooning using a buddy wire may be considered. Cutting balloon angioplasty with fenestration and decompression of the false lumen may be preferable to stent implantation for preventing proximal extension of an intramural hematoma and the need for a long stent (5). Intramural hematomas may be resolved with cutting balloon angioplasty; chronic total occlusion wires may be used as an alternative treatment strategy in SCAD (6).