Spontaneous coronary artery dissection percutaneous coronary intervention

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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

Type 2A

Type 2B

Type 3

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Arzu Kalayci, M.D. [2] Nate Michalak, B.A.

Synonyms and keywords: SCAD

Overview

Conservative management should be first choice if emergent revascularization is not necessary. [1] However, the optimal management is in question due to the insufficient clinical experience. There are some treatment options including conservative management, emergency revascularization (PCI or CABG), fibrinolytic therapy, mechanical hemodynamic support, and even cardiac transplantation have been reported. Preference of the approach should be tailored to patient’s clinical status. [2] [3] [4] [5]


Percutaneous Coronary Intervention

Revascularization should be considered in case of acute myocardial infarction with symptoms or haemodynamic instability. [2] However, PCI is technically quite difficult with a high risk of complications.[6] [7] Therefore, conservative management is recommended in patients with non-occlusive luminal obstruction, TIMI grade 3 flow and a stable clinical condition. Performing PCI in SCAD is technically very difficult due to the arterial fragility. It can be quite challenging to keep the guide wire within the true lumen while crossing the lesion. Any instruments using in the each stages such as wiring, angioplasty, or stenting can enlarge the dissection and block side branches. In addition, these lesions are mostly require long stents resulting in higher rates of in stent restenosis. Furthermore, resorption of the intramural hematoma may lead to late strut malapposition and stent thrombosis. Therefore, stent implantation should only be performed in a strong clinical indication. It would be beneficial to perform procedure under the guidance of intracoronary imaging (IVUS, OCT). Although there is no evidence about the benefits of bioabsorbable stents, theoretically it seems to have advantages. [8]



Conservative management should be first choice if emergent revascularization is not necessary.[1] PCI is indicated in the presence of ongoing myocardial ischemia or myocardial infarction.[9] 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. [10]

References

  1. ↑ 1.0 1.1 Tweet MS, Eleid MF, Best PJ, Lennon RJ, Lerman A, Rihal CS; et al. (2014). "Spontaneous coronary artery dissection: revascularization versus conservative therapy". Circ Cardiovasc Interv. 7 (6): 777–86. doi:10.1161/CIRCINTERVENTIONS.114.001659. PMID 25406203.
  2. ↑ 2.0 2.1 Saw J, Aymong E, Sedlak T, Buller CE, Starovoytov A, Ricci D; et al. (2014). "Spontaneous coronary artery dissection: association with predisposing arteriopathies and precipitating stressors and cardiovascular outcomes". Circ Cardiovasc Interv. 7 (5): 645–55. doi:10.1161/CIRCINTERVENTIONS.114.001760. PMID 25294399.
  3. ↑ Saw J, Aymong E, Mancini GB, Sedlak T, Starovoytov A, Ricci D (2014). dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24726091 "Nonatherosclerotic coronary artery disease in young women" Check |url= value (help). Can J Cardiol. 30 (7): 814–9. doi:10.1016/j.cjca.2014.01.011. PMID 24726091.
  4. ↑ Alfonso F, Paulo M, Lennie V, Dutary J, Bernardo E, Jiménez-Quevedo P; et al. (2012). "Spontaneous coronary artery dissection: long-term follow-up of a large series of patients prospectively managed with a "conservative" therapeutic strategy". JACC Cardiovasc Interv. 5 (10): 1062–70. doi:10.1016/j.jcin.2012.06.014. PMID 23078737.
  5. ↑ Higgins GL, Borofsky JS, Irish CB, Cochran TS, Strout TD (2013). "Spontaneous peripartum coronary artery dissection presentation and outcome". J Am Board Fam Med. 26 (1): 82–9. doi:10.3122/jabfm.2013.01.120019. PMID 23288285.
  6. ↑ Tweet MS, Hayes SN, Pitta SR, Simari RD, Lerman A, Lennon RJ; et al. (2012). "Clinical features, management, and prognosis of spontaneous coronary artery dissection". Circulation. 126 (5): 579–88. doi:10.1161/CIRCULATIONAHA.112.105718. PMID 22800851.
  7. ↑ Vrints CJ (2010). "Spontaneous coronary artery dissection". Heart. 96 (10): 801–8. doi:10.1136/hrt.2008.162073. PMID 20448134.
  8. ↑ Vijayaraghavan R, Verma S, Gupta N, Saw J (2014). "Pregnancy-related spontaneous coronary artery dissection". Circulation. 130 (21): 1915–20. doi:10.1161/CIRCULATIONAHA.114.011422. PMID 25403597.
  9. ↑ Adlam D, Cuculi F, Lim C, Banning A (2010). "Management of spontaneous coronary artery dissection in the primary percutaneous coronary intervention era". The Journal of Invasive Cardiology. 22 (11): 549–53. PMID 21041853.
  10. ↑ Saw J, Mancini GBJ, Humphries KH (2016). "Contemporary Review on Spontaneous Coronary Artery Dissection". J Am Coll Cardiol. 68 (3): 297–312. doi:10.1016/j.jacc.2016.05.034. PMID 27417009.
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