Spontaneous Coronary Artery Dissection

Abstract

Spontaneous coronary artery dissection (SCAD) is a rare cause of acute myocardial infarction (ACS). We report a case of acute coronary syndrome due to SCAD of the right coronary artery. Diagnosis was based on clinical presentation and coronary angiography, and confirmed by optical coherence tomography which guided our treatment strategy. (Level of Difficulty: Beginner.)

Graphical abstract

Case Description

A 34-year-old woman was admitted for chest pain that occurred while dancing. The initial assessment showed a pain-free patient with a normal electrocardiogram. Results of blood tests were normal, except for 2 elevated troponin values (2.4 and 3.9 μg/l [normal ≤0.045]). A coronary angiogram showed a normal left coronary artery system and limited luminal narrowing (30%) in the midsegment of the right coronary artery. This finding was suggestive of a spontaneous coronary hematoma. Immediately following our first injection, we noticed stagnation of contrast material all over artery starting from the ostium, with a total-lumen tear. The hypothesis was that the coronary hematoma had ruptured under the effect of the hydraulic pressure and had transformed into a dissection (Figure 1A). Surprisingly, the patient was pain free. In the hope of treating this condition, we performed optical coherence tomography (OCT), which showed the progression of the guidewire and the optical fiber into the false lumen because the true lumen was completely collapsed, with an “apple turnover” aspect from the first centimeter of the artery (Figure 1Aʹ, Video 1). Several attempts to rewire the true lumen were unsuccessful, and a watchful strategy was adopted. On her fourth hospital day, the patient had a new chest pain with inferior ST-segment elevation that mandated a new angiogram. This imaging showed an aspect of the artery completely torn from the ostium and a line of dissection extending to the posterior descending artery. Medical therapy was deemed more appropriate than angioplasty. She was discharged with beta-blocker and antiplatelet therapy with inverted T waves in the inferior leads. At 2 months, the patient underwent exercise stress single-photon emission computed tomography that showed ischemia in the inferior coronary artery territory. A coronary angiogram revealed chronic occlusion of the right coronary artery without collateral circulation (Figure 1B, Video 2). Despite attempts made under OCT guidance (Figure 1Bʹ, Video 3), wiring the true lumen proved impossible. Therefore, we opted for a dissection re-entry strategy. The re-entry occurred in the posterior descending artery and was confirmed by an injection through a Caravel microcatheter (Asahi Intecc, Tokyo, Japan). On this basis, we subsequently implanted 3 drug-eluting stents. Final angiography (Figure 1C, Video 4) showed an excellent result, with Thrombolysis In Myocardial Infarction flow grade 3. The final OCT imaging (Figure 1Cʹ, Video 5) revealed well-apposed stents, but the true lumen was outside the stents. The patient was free of cardiac-related events 12 months after the procedure. The attempted primary angioplasty and the wiring of the false lumen may have led to poor spontaneous healing and a transition to chronic occlusion that was manifested by ischemia on further follow-up. OCT was used to guide angioplasty by distinguishing the true lumen from the false lumen.

Figure 1.

Spontaneous Coronary Artery Dissection

(A) Coronary angiography showing dissection of the right coronary artery. (Aʹ) Spontaneous coronary artery dissection confirmed by optical coherence tomography. The true lumen (asterisks) is compressed by an intramural hematoma. (B) Chronic occlusive dissection of the right coronary artery. (Bʹ) Optical frequency domain imaging: The guidewire is inside the false lumen in the first 9 cm. (C) Final result after stenting. (Cʹ) Well-apposed stents on optical coherence tomography with the true lumen (asterisks) outside the stents.

Author Disclosures

The authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Appendix

Supplemental Video 1

OCT Imaging in the Acute Phase

Supplemental Video 2

Coronary Angiography of the Right Coronary Artery 2 Months Later

Supplemental Video 3

OFDI Before and After Angioplasty

Supplemental Video 4

Angiography of the Right Coronary Artery After Angioplasty

Supplemental Video 5

OFDI Before and After Angioplasty