Coronary artery dissection classification
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]
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Definition
Dissection is an intraluminal filling defect or flap associated with a hazy, ground-glass appearance. This category is sub-classified using the NHLBI (National Heart Lung and Blood Institute) system for grading dissection types:
Type A
Radiolucent areas within the coronary lumen during contrast injection, with minimal or no persistence of contrast after dye has cleared.
Type B
Parallel tracts or double lumen separated by a radiolucent area during contrast injection, with minimal or no persistence after dye has cleared.
Type C
Contrast outside the coronary lumen, with persistence of contrast in the area after dye has cleared.
Type D
Spiral luminal filling defects frequently with extensive contrast staining of the vessel.
Type E
New persistent filling defects that may be caused by thrombus.
Type F
These are non A – E dissection types that lead to impaired flow or total occlusion of the coronary artery.
Pathophysiology
Most coronary disseactions occur as a result of percutaneous coronary intervention, but they may also occur either as an extension of an aortic dissection into the right coronary artery, or in the settig of coronary bypass grafting. Spontaneous coronary dissection in the coronary artery is itself rare.
Spontaneous coronary dissection
The majority of dissections occur following percutaneous coronary intervention (PCI). However, coronary dissections can rarely occur spontaneously. The literature is sparse with only 150 cases of spontaneous dissection reported in the world's literature.
Epidemiology of spontaneous coronary dissection and risk factors
The majority (80%) occurs in Young women in the peripartum period or ingesting birth control pills seem to be at particular risk. It has been hypothesized that the strain of childbirth and the release of systemic factors such as relaxin underly the increased risk. Spontaneous dissection is rarely a cause of acute coronary syndrome.
Diagnosis of spontaneous coronary dissection
In the past, this disorder was rarely diagnosed during life on the angiogram, and was more often diagnosed at the time of autopsy. The signs and symptoms are indistinguishable from those of acute coronary syndromes.
Prognosis of spontaneous coronary dissection
The fact that the diagnosis was made so often in the past on autopsy speaks to the poor clinical outcomes that have been associated with the condition. Outcomes in the modern era of stent placement and improved antithrombins may be improved, but solid data are lacking.
=Treatment of spontaneous coronary dissection
Coronary stent placement and anticoagulation would appear to be reasonable treatment modalities. Given the rare nature of the disease, randomized trial data is obviously lacking.