Abstract
Spontaneous coronary artery dissections (SCAD) are often difficult to diagnose and manage. Intravascular imaging such as optical coherence tomography (OCT) improves diagnosis and may assist in management. Recent data suggest that percutaneous coronary interventions (PCI) in in SCAD are associated with poor outcomes. This report provides striking OCT images of potential complications associated with PCI in SCAD, as well as demonstrates medium term OCT data in residual hematoma healing and stent coverage in SCAD.
A 52-year-old post-menopausal female presented with an antero-lateral non-ST segment elevation acute coronary syndrome. Despite maximal management with beta-blockers, intravenous nitroglycerine and tirofiban infusion in the coronary care unit, she had recurred breakthrough chest pain with further ischaemic electrocardiographic changes. Emergency coronary angiography demonstrated single vessel disease, with a diffuse stenosis affecting the mid to distal portion of the left anterior descending (LAD) artery ( Fig. 1 A ), consistent with spontaneous coronary artery dissection (SCAD); there was no atherosclerosis in other vessels. Due to ongoing chest pains, percutaneous coronary intervention was performed on this culprit vessel; in a conventional manner, stents were to be placed in a distal-to-proximal direction. A 2.5 mm×33 mm Xience PRIME drug eluting stent (DES) (Abbott Vascular, Santa Clara, CA, USA) was deployed in this mid segment. This created significant luminal compromise proximal to the stent ( Fig. 1 B), causing severe chest pain. A second DES (3.0 mm×15 mm Xience PRIME) was promptly placed proximal to restore flow. This led to a similar iatrogenic “stenosis” proximally ( Fig. 1 C), which again failed to resolve with intracoronary nitrate. Optical coherence tomography (OCT) not only confirmed SCAD, otherwise well apposed stents, but also revealed an intramural hematoma proximal to the stent compromising flow ( Fig. 2 , top panel). A third stent (3.0 mm×12 mm Xience PRIME) was then placed proximal to, and overlapping, the second stent. Whilst luminal patency had been restored, haziness was noted at the ostium of the large first diagonal artery (LADD) ( Fig. 1 D, arrow). A repeat OCT ( Fig. 2 , bottom panel) revealed further extension of the hematoma stopping at just proximal to the diagonal artery ostium. No further stent was placed due to concerns for further propagation. The patient experienced no further chest pain and was discharged on day 3.
