Spontaneous coronary artery dissection percutaneous coronary intervention

Spontaneous Coronary Artery Dissection Microchapters
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Overview
Historical Perspective
Classification
Pathophysiology
Causes
Differentiating Spontaneous coronary artery dissection from other Diseases
Epidemiology and Demographics
Risk Factors
Screening
Natural History, Complications and Prognosis
Diagnosis
Diagnostic Approach
History and Symptoms
Physical Examination
Laboratory Findings
Electrocardiogram
Angiography
CT
MRI
Echocardiography
Other Imaging Findings
Other Diagnostic Studies
Treatment
Treatment Approach
Medical Therapy
Percutaneous Coronary Intervention
Surgery
Primary Prevention
Secondary Prevention
Cost-Effectiveness of Therapy
Future or Investigational Therapies
Case Studies
Type 1 Case 1 Case 2 Case 3 Case 4 Case 5 Case 6 Case 7 Type 2A Case 1 Case 2 Case 3 Case 4 Case 5 Case 6 Type 2B Case 1 Case 2 Case 3 Case 4 Type 3 Case 1 Case 2 Case 3 Case 4 Case 5 Case 6

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

Percutaneous Coronary Intervention

Conservative management should be first choice if emergency revascularization is not necessary. PCI is indicated in the presence of ongoing myocardial ischemia or myocardial infarction. Drug eluting stents (DES) are routinely used in the management of SCAD. However, their impact on long-term outcomes has not been assessed yet in clinical studies.

Challenges and Suggestions With SCAD PCI
Challenges during PCI of SCAD
Risk of iatrogenic catheter-induced dissection
Difficulty advancing coronary wire into distal true lumen
Propagating IMH anterograde and retrograde with angioplasty/ stenting, extending dissection and further compromising true lumen arterial flow
Dissection tends to extend into distal arteries, which are too small for stents
Often extensive dissected segments require long stents, increasing stent restenosis
Risk of stent malapposition after resorption of IMH, with risk of late stent thrombosis
Suggestions if PCI is pursued for SCAD
Meticulous guide catheter manipulation, preferably through femoral access approach
OCT/IVUS guidance to ensure wire in true lumen (or over-the-wire catheter injections) and optimize stent apposition
Long stents covering 5-10 mm of proximal and distal edges of IMH
Placing short stents at proximal and distal edges first, before placing long stent in the middle
Consider bioabsorbable stents (temporary scaffold to avoid longterm malapposition)
Possible and careful use of cutting balloon (to fenestrate IMH)
Consider follow-up OCT to assess for malapposed/ uncovered struts before stopping DAPT
DAPT= dual antiplatelet therapy; IMH= intramural hematoma; IVUS= intravascular ultrasound; PCI= percutaneous coronary intervention.