Spontaneous coronary artery dissection classification: Difference between revisions
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__NOTOC__ | __NOTOC__ | ||
{{Spontaneous coronary artery dissection}} | {{Spontaneous coronary artery dissection}} | ||
{{CMG}}; {{AE}} {{NRM}} | {{CMG}}; {{AE}} {{NRM}}; {{AKK}} | ||
{{SK}} SCAD | {{SK}} SCAD | ||
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==Overview== | ==Overview== | ||
[[Spontaneous coronary artery dissection]] can be classified based on [[angiographic]] appearance into type 1 (evident [[arterial]] wall stain with multiple [[radiolucent ]][[lumens]]), type 2 (diffuse [[smooth]] [[stenosis]] of varying severity), and type 3 [[lesions]] ([[focal]] or [[tubular]] [[stenosis]] mimicking [[atherosclerosis]]). Type 4 [[SCAD]] [[lesion]] is characterized by [[dissection]] leading to an abrupt total [[occlusion]], usually of a distal [[coronary]] segment. The [[total occlusion]] occurs as a result of diminished true [[lumen]] due to external compression by [[intraluminal]] [[hematoma]] rather than [[embolism]]. The intermediate type 1/2 [[SCAD]] [[lesion]] is characterized by the appearance of type 1 in conjunction with type 2 [[lesion]]. | |||
==Classification== | ==Classification== | ||
The National Heart, Lung, and Blood Institute (NHLBI) classification scheme for [[coronary dissection]] was devised in the pre-stent era for classifying the dissection following balloon angioplasty (i.e., iatrogenic dissection). In light of the distinctive angiographic features of spontaneous coronary artery dissection (SCAD), Saw et al. proposed a classification system to better characterize the lesions:<ref name="pmid24227590">{{cite journal| author=Saw J| title=Coronary angiogram classification of spontaneous coronary artery dissection. | journal=Catheter Cardiovasc Interv | year= 2014 | volume= 84 | issue= 7 | pages= 1115-22 | pmid=24227590 | doi=10.1002/ccd.25293 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24227590 }} </ref><ref name="pmid26198289">{{cite journal| author=Saw J, Mancini GB, Humphries K, Fung A, Boone R, Starovoytov A et al.| title=Angiographic appearance of spontaneous coronary artery dissection with intramural hematoma proven on intracoronary imaging. | journal=Catheter Cardiovasc Interv | year= 2016 | volume= 87 | issue= 2 | pages= E54-61 | pmid=26198289 | doi=10.1002/ccd.26022 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26198289 }} </ref> | The National Heart, Lung, and Blood Institute (NHLBI) classification scheme for [[coronary dissection]] was devised in the pre-stent era for classifying the [[dissection]] following balloon [[angioplasty]] (i.e., [[iatrogenic dissection]]). In light of the distinctive [[angiographic]] features of [[spontaneous coronary artery dissection]] ([[SCAD]]), Saw et al. proposed a classification system to better characterize the [[lesions]]:<ref name="pmid24227590">{{cite journal| author=Saw J| title=Coronary angiogram classification of spontaneous coronary artery dissection. | journal=Catheter Cardiovasc Interv | year= 2014 | volume= 84 | issue= 7 | pages= 1115-22 | pmid=24227590 | doi=10.1002/ccd.25293 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24227590 }} </ref><ref name="pmid26198289">{{cite journal| author=Saw J, Mancini GB, Humphries K, Fung A, Boone R, Starovoytov A et al.| title=Angiographic appearance of spontaneous coronary artery dissection with intramural hematoma proven on intracoronary imaging. | journal=Catheter Cardiovasc Interv | year= 2016 | volume= 87 | issue= 2 | pages= E54-61 | pmid=26198289 | doi=10.1002/ccd.26022 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26198289 }} </ref><ref name="Al-HussainiAdlam2017">{{cite journal|last1=Al-Hussaini|first1=Abtehale|last2=Adlam|first2=David|title=Spontaneous coronary artery dissection|journal=Heart|volume=103|issue=13|year=2017|pages=1043–1051|issn=1355-6037|doi=10.1136/heartjnl-2016-310320}}</ref><ref name="AdlamAlfonso2018">{{cite journal|last1=Adlam|first1=David|last2=Alfonso|first2=Fernando|last3=Maas|first3=Angela|last4=Vrints|first4=Christiaan|last5=al-Hussaini|first5=Abtehale|last6=Bueno|first6=Hector|last7=Capranzano|first7=Piera|last8=Gevaert|first8=Sofie|last9=Hoole|first9=Stephen P|last10=Johnson|first10=Tom|last11=Lettieri|first11=Corrado|last12=Maeder|first12=Micha T|last13=Motreff|first13=Pascal|last14=Ong|first14=Peter|last15=Persu|first15=Alexandre|last16=Rickli|first16=Hans|last17=Schiele|first17=Francois|last18=Sheppard|first18=Mary N|last19=Swahn|first19=Eva|title=European Society of Cardiology, acute cardiovascular care association, SCAD study group: a position paper on spontaneous coronary artery dissection|journal=European Heart Journal|year=2018|issn=0195-668X|doi=10.1093/eurheartj/ehy080}}</ref><ref name="KimLongo2020">{{cite journal|last1=Kim|first1=Esther S.H.|last2=Longo|first2=Dan L.|title=Spontaneous Coronary-Artery Dissection|journal=New England Journal of Medicine|volume=383|issue=24|year=2020|pages=2358–2370|issn=0028-4793|doi=10.1056/NEJMra2001524}}</ref> | ||
{| class="wikitable" style="font-size: 85%;" | {| class="wikitable" style="font-size: 85%;" | ||
! style="background: #4479BA; text-align: center; width: | ! style="background: #4479BA; text-align: center; width: 150px;" |{{fontcolor|#FFF|Type}} | ||
! style="background: #4479BA; text-align: center; width: | ! style="background: #4479BA; text-align: center; width: 850px;" colspan=2 | {{fontcolor|#FFF|Feature}} | ||
|- | |- | ||
| style="background: #DCDCDC; padding: 5px; text-align: center;" | '''Type 1''' | | style="background: #DCDCDC; padding: 5px; text-align: center;" | '''Type 1''' | ||
| style="background: #F5F5F5; padding: 5px;" colspan="2;"| | | style="background: #F5F5F5; padding: 5px;" colspan="2;"| | ||
*Pathognomonic multiple radiolucent lumen | * Pathognomonic multiple [[radiolucent]] lumen | ||
*Contrast dye staining of arterial wall | * Contrast dye staining of [[arterial]] wall | ||
*Presence or absence of dye hang-up or slow contrast clearing from the | * Presence or absence of [[dye]] hang-up or slow contrast clearing from the [[lumen]] | ||
|- | |- | ||
| style="background: #DCDCDC; padding: 5px; text-align: center;" rowspan="3;" | '''Type 2''' | | style="background: #DCDCDC; padding: 5px; text-align: center;" rowspan="3;" | '''Type 2''' | ||
| style="background: #F5F5F5; padding: 5px;" colspan="2;"| | | style="background: #F5F5F5; padding: 5px;" colspan="2;"| | ||
*Diffuse (typically >20–30 mm) | * The most common form (60-75% of the [[patients]]) | ||
*Smooth narrowing varying in severity (ranging from 40 to 100% stenosis) | * Diffuse (typically >20–30 mm) | ||
*No response to intracoronary nitroglycerin | * Smooth narrowing varying in severity (ranging from 40 to 100% stenosis) | ||
*No atherosclerotic lesions in other coronary arteries | * Appears as a sudden change in the caliber of the [[artery]] | ||
*Repeat coronary angiogram showing spontaneous resolution of the dissected segment or previous | * No response to [[intracoronary]] [[nitroglycerin]] | ||
* No [[atherosclerotic]] lesions in other [[coronary arteries]] | |||
* Repeat [[coronary angiogram]] showing spontaneous resolution of the [[dissected]] segment or previous [[angiogram]] showing normal [[artery]] | |||
* Intracoronary imaging with [[OCT]] or [[IVUS]] proving the presence of [[intramural]] [[hematoma]] and double-[[lumen]] | |||
|- | |- | ||
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''2A variant''' | | style="background: #F5F5F5; padding: 5px; text-align: center;"| '''2A variant''' | ||
| style="background: #F5F5F5; padding: 5px;" |Normal arterial caliber proximal and distal to dissection | | style="background: #F5F5F5; padding: 5px;" |Normal [[arterial]] caliber proximal and distal to [[dissection]] | ||
|- | |- | ||
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''2B variant''' | | style="background: #F5F5F5; padding: 5px; text-align: center;"| '''2B variant''' | ||
| style="background: #F5F5F5; padding: 5px;" |Dissection extends to the distal tip of the artery without discernible normal segment distally | | style="background: #F5F5F5; padding: 5px;" |Dissection extends to the distal tip of the [[artery]] without discernible normal segment distally | ||
|- | |- | ||
| style="background: #DCDCDC; padding: 5px; text-align: center;" | '''Type 3''' | | style="background: #DCDCDC; padding: 5px; text-align: center;" | '''Type 3''' | ||
| style="background: #F5F5F5; padding: 5px;" colspan="2;"| | | style="background: #F5F5F5; padding: 5px;" colspan="2;"| | ||
*Mimics atherosclerosis with focal or tubular stenosis | * Mimics [[atherosclerosis]] with focal or [[tubular stenosis]] | ||
*Lack of atherosclerotic changes in other coronary arteries | * Lack of [[atherosclerotic]] changes in other [[coronary arteries]] | ||
*Long lesions (11–20 mm) | * Long lesions (11–20 mm) | ||
*Hazy stenosis | * Hazy [[stenosis]] | ||
*Linear stenosis | * Linear [[stenosis]] | ||
*Note: requires OCT or IVUS to prove the presence of intramural hematoma or double-lumen | * Note: requires [[OCT]] or [[IVUS]] to prove the presence of intramural [[hematoma]] or double-lumen | ||
| style="background: # | |- | ||
| style="background: #DCDCDC; padding: 5px; text-align: center;" | '''Type 4''' | |||
| style="background: #F5F5F5; padding: 5px;" colspan="2;"| | |||
* Abrupt total vessel occlusion | |||
* Usually involves a distal segment | |||
* Sources of [[coronary embolism]] have been excluded | |||
* Subsequent evidence of complete vessel healing in keeping with the natural history of [[SCAD]] | |||
|- | |||
| style="background: #DCDCDC; padding: 5px; text-align: center;" | '''Intermediate Type 1/2''' | |||
| style="background: #F5F5F5; padding: 5px;" colspan="2;"| | |||
* Diffuse smooth narrowing (type 2 appearance) | |||
* [[Arterial]] wall stain with multiple radiolucent lumens in keeping with a localized fenestration between true and [[false lumen]] (type 1 appearance) | |||
|- | |||
|} | |} | ||
==Spontaneous Coronary Artery Dissection Type 1== | ==Spontaneous Coronary Artery Dissection Type 1== | ||
Type 1 SCAD lesion is characterized by the pathognomonic appearance of arterial wall | Type 1 [[SCAD]] [[lesion]] is characterized by the pathognomonic appearance of contrast dye staining of the [[arterial]] wall with multiple [[radiolucent]] [[lumens]], with or without the presence of [[dye]] hang-up or [[slow]] [[contrast]] clearing from the [[lumen]]. | ||
[[File:28-2-type-1-14RAO35CRA.gif|500px|]] | |||
[[File:28-2 type 1 14RAO35CRA.jpg|500px|]] | |||
<span style="font-size:85%">Projection angle: 14 RAO, 35 CRA. Type 1 [[SCAD]] is seen in [[OM]]2.</span> | |||
==[[Spontaneous Coronary Artery Dissection]] Type 2== | |||
Type 2 [[SCAD]] [[lesion]] is characterized by diffuse (typically >20–30 mm) and usually smooth narrowing that can vary in severity from inconspicuous mild [[stenosis]] to complete [[occlusion]], plus: | |||
: a. no response to intracoronary [[nitroglycerin]] and no [[atherosclerotic]] [[lesions]] in other [[coronary arteries]] | |||
: '''OR''' | |||
: b. repeat [[coronary]] [[angiogram]] showing [[angiographic]] resolution of the [[dissected segment]] or previous [[angiogram]] showing [[normal]] [[artery]] | |||
: '''OR''' | |||
: c. intracoronary [[imaging]] with [[optical coherence tomography]] or [[intravascular ultrasound]] proving the presence of intramural [[hematoma]] ([[IMH]]) and double-[[lumen]] | |||
Type 2 [[SCAD]] [[lesion]] commonly involves the mid to distal segments of [[coronary arteries]] and can be so extensive that it affects the distal tip. Accordingly, type 2 [[lesions]] can be further divided into two variants (type 2 variant A and variant B). | |||
===Type 2 Variant A=== | |||
In type 2 variant A [[lesion]], the coronary segments proximal and distal to [[dissection]] are normal. | |||
[[File:1-1-type-2A-RAD-25LAO20CRA.gif|500px|]] | |||
[[File:1-1 type 2A RAD 25LAO20CRA.jpg|500px|]] | |||
<span style="font-size:85%">Projection angle: 25 [[LAO]], 20 CRA. Type 2A [[SCAD]] is seen in R3, R4.</span> | |||
===Type 2 Variant B=== | |||
In type 2 variant B [[lesion]], the dissection extends to the [[apical]] tip of the [[artery]] without discernible normal segment distally. | |||
[[File:24-1-type-2B-LAD-41RAO19CRA-TFG0.gif|500px|]] | |||
[[File:24-1 type 2B LAD 41RAO19CRA TFG0.jpg|500px|]] | |||
[[ | <span style="font-size:85%">Projection angle: 41 [[RAO]], 19 CRA. Type 2B [[SCAD]] is seen starting in L2 resulting in a total [[occlusion]].</span> | ||
[[ | |||
==Spontaneous Coronary Artery Dissection Type 3== | |||
Type 3 [[SCAD]] [[lesion]] is characterized by focal or [[tubular]] (typically <20 mm) [[stenosis]] that mimics [[atherosclerosis]], which requires [[intracoronary]] [[imaging]] (e.g. [[optical coherence tomography]] or [[intravascular ultrasound]]) to prove the presence of intramural [[hematoma]] or double-lumen. [[Angiographic]] features that may be useful in differentiating type 3 [[SCAD]] [[lesion]] from [[atherosclerosis]] include: | |||
[[ | : a. lack of [[atherosclerotic]] changes in other [[coronary arteries]] | ||
[[ | : b. long [[lesions]] (11–20 mm) | ||
: c. hazy [[stenosis]] | |||
: d. linear [[stenosis]] | |||
[[File:11-1 type 2B&3 1 LAO35CRA.gif|500px|]] | |||
[[File:11-1 type 2B&3 1 LAO35CRA.jpg|500px|]] | |||
= | <span style="font-size:85%">[[Projection angle]]: 1 [[LAO]], 35 CRA. Type 3 SCAD is seen in D1.</span> | ||
[[ | |||
[[ | |||
==[[Spontaneous Coronary Artery Dissection]] Type 4== | |||
Type 4 [[SCAD]] [[lesion]] is characterized by [[dissection]] leading to an abrupt total [[occlusion]], usually of a distal [[coronary]] segment. The [[total occlusion]] occurs as a result of diminished true [[lumen]] due to external compression by [[intraluminal]] [[hematoma]] rather than [[embolism]]. In keeping with the natural history of [[SCAD]], spontaneous healing may be evident on subsequent [[angiography]]. | |||
[[ | |||
[[ | |||
==[[Spontaneous Coronary Artery Dissection]] Intermediate Type 1/2== | |||
The intermediate type 1/2 [[SCAD]] [[lesion]] is characterized by the appearance of type 1 in conjunction with type 2 [[lesion]]. Diffuse, smooth narrowing of the [[vessel]] (suggestive of type 2 [[lesion]]) adjacent to multiple [[radiolucent]] [[lumens]] with [[arterial]] [[wall]] staining (suggestive of a type 1 [[lesion]]) is observed. | |||
==References== | ==References== | ||
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[[Category:Angiographic Definitions]] | [[Category:Angiographic Definitions]] | ||
[[Category:Disease]] | [[Category:Disease]] | ||
[[Category:Up To Date]] | |||
Latest revision as of 12:47, 20 April 2021
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Spontaneous Coronary Artery Dissection Microchapters |
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Differentiating Spontaneous coronary artery dissection from other Diseases |
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Diagnosis |
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Treatment |
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Case Studies |
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Type 1 Type 2A Type 2B Type 3 |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Nate Michalak, B.A.; Arzu Kalayci, M.D. [2]
Synonyms and keywords: SCAD
Overview
Spontaneous coronary artery dissection can be classified based on angiographic appearance into type 1 (evident arterial wall stain with multiple radiolucent lumens), type 2 (diffuse smooth stenosis of varying severity), and type 3 lesions (focal or tubular stenosis mimicking atherosclerosis). Type 4 SCAD lesion is characterized by dissection leading to an abrupt total occlusion, usually of a distal coronary segment. The total occlusion occurs as a result of diminished true lumen due to external compression by intraluminal hematoma rather than embolism. The intermediate type 1/2 SCAD lesion is characterized by the appearance of type 1 in conjunction with type 2 lesion.
Classification
The National Heart, Lung, and Blood Institute (NHLBI) classification scheme for coronary dissection was devised in the pre-stent era for classifying the dissection following balloon angioplasty (i.e., iatrogenic dissection). In light of the distinctive angiographic features of spontaneous coronary artery dissection (SCAD), Saw et al. proposed a classification system to better characterize the lesions:[1][2][3][4][5]
| Type | Feature | |
|---|---|---|
| Type 1 |
| |
| Type 2 |
| |
| 2A variant | Normal arterial caliber proximal and distal to dissection | |
| 2B variant | Dissection extends to the distal tip of the artery without discernible normal segment distally | |
| Type 3 |
| |
| Type 4 |
| |
| Intermediate Type 1/2 |
| |
Spontaneous Coronary Artery Dissection Type 1
Type 1 SCAD lesion is characterized by the pathognomonic appearance of contrast dye staining of the arterial wall with multiple radiolucent lumens, with or without the presence of dye hang-up or slow contrast clearing from the lumen.
Projection angle: 14 RAO, 35 CRA. Type 1 SCAD is seen in OM2.
Spontaneous Coronary Artery Dissection Type 2
Type 2 SCAD lesion is characterized by diffuse (typically >20–30 mm) and usually smooth narrowing that can vary in severity from inconspicuous mild stenosis to complete occlusion, plus:
- a. no response to intracoronary nitroglycerin and no atherosclerotic lesions in other coronary arteries
- OR
- b. repeat coronary angiogram showing angiographic resolution of the dissected segment or previous angiogram showing normal artery
- OR
- c. intracoronary imaging with optical coherence tomography or intravascular ultrasound proving the presence of intramural hematoma (IMH) and double-lumen
Type 2 SCAD lesion commonly involves the mid to distal segments of coronary arteries and can be so extensive that it affects the distal tip. Accordingly, type 2 lesions can be further divided into two variants (type 2 variant A and variant B).
Type 2 Variant A
In type 2 variant A lesion, the coronary segments proximal and distal to dissection are normal.
Projection angle: 25 LAO, 20 CRA. Type 2A SCAD is seen in R3, R4.
Type 2 Variant B
In type 2 variant B lesion, the dissection extends to the apical tip of the artery without discernible normal segment distally.
Projection angle: 41 RAO, 19 CRA. Type 2B SCAD is seen starting in L2 resulting in a total occlusion.
Spontaneous Coronary Artery Dissection Type 3
Type 3 SCAD lesion is characterized by focal or tubular (typically <20 mm) stenosis that mimics atherosclerosis, which requires intracoronary imaging (e.g. optical coherence tomography or intravascular ultrasound) to prove the presence of intramural hematoma or double-lumen. Angiographic features that may be useful in differentiating type 3 SCAD lesion from atherosclerosis include:
- a. lack of atherosclerotic changes in other coronary arteries
- b. long lesions (11–20 mm)
- c. hazy stenosis
- d. linear stenosis
Projection angle: 1 LAO, 35 CRA. Type 3 SCAD is seen in D1.
Spontaneous Coronary Artery Dissection Type 4
Type 4 SCAD lesion is characterized by dissection leading to an abrupt total occlusion, usually of a distal coronary segment. The total occlusion occurs as a result of diminished true lumen due to external compression by intraluminal hematoma rather than embolism. In keeping with the natural history of SCAD, spontaneous healing may be evident on subsequent angiography.
Spontaneous Coronary Artery Dissection Intermediate Type 1/2
The intermediate type 1/2 SCAD lesion is characterized by the appearance of type 1 in conjunction with type 2 lesion. Diffuse, smooth narrowing of the vessel (suggestive of type 2 lesion) adjacent to multiple radiolucent lumens with arterial wall staining (suggestive of a type 1 lesion) is observed.
References
- ↑ Saw J (2014). "Coronary angiogram classification of spontaneous coronary artery dissection". Catheter Cardiovasc Interv. 84 (7): 1115–22. doi:10.1002/ccd.25293. PMID 24227590.
- ↑ Saw J, Mancini GB, Humphries K, Fung A, Boone R, Starovoytov A; et al. (2016). "Angiographic appearance of spontaneous coronary artery dissection with intramural hematoma proven on intracoronary imaging". Catheter Cardiovasc Interv. 87 (2): E54–61. doi:10.1002/ccd.26022. PMID 26198289.
- ↑ Al-Hussaini, Abtehale; Adlam, David (2017). "Spontaneous coronary artery dissection". Heart. 103 (13): 1043–1051. doi:10.1136/heartjnl-2016-310320. ISSN 1355-6037.
- ↑ Adlam, David; Alfonso, Fernando; Maas, Angela; Vrints, Christiaan; al-Hussaini, Abtehale; Bueno, Hector; Capranzano, Piera; Gevaert, Sofie; Hoole, Stephen P; Johnson, Tom; Lettieri, Corrado; Maeder, Micha T; Motreff, Pascal; Ong, Peter; Persu, Alexandre; Rickli, Hans; Schiele, Francois; Sheppard, Mary N; Swahn, Eva (2018). "European Society of Cardiology, acute cardiovascular care association, SCAD study group: a position paper on spontaneous coronary artery dissection". European Heart Journal. doi:10.1093/eurheartj/ehy080. ISSN 0195-668X.
- ↑ Kim, Esther S.H.; Longo, Dan L. (2020). "Spontaneous Coronary-Artery Dissection". New England Journal of Medicine. 383 (24): 2358–2370. doi:10.1056/NEJMra2001524. ISSN 0028-4793.