Summary
Spontaneous coronary artery dissection (SCAD) is an under-recognised presentation of acute coronary syndrome. A high index of suspicion is essential. If diagnostic doubt is high, intracoronary imaging, performed carefully, can be useful, although it can result in worsening of the clinical condition. The current report exemplifies the complexity of diagnosis and management of SCAD in a patient with out-of-hospital cardiac arrest and non-diagnostic angiography.
Highlights
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Intravascular imaging is required to detect coronary intramural hematoma.
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SCAD affected arteries require extra care during wire and device manipulation.
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Cutting balloons can be used for treatment of SCAD.
1
Introduction
Spontaneous coronary artery dissection (SCAD) is an under-recognised cause of acute coronary syndrome (ACS). The prevalence of SCAD ranges from 1.7–4% of ACS patients, with ≥90% of cases affecting females [ ]. The majority of SCAD have clear demarcation between the normal and affected segment of the artery. Where diagnosis is not clear from coronary angiography, intracoronary imaging, performed carefully, can be useful.
1.1
Case report
A 51 year old woman, with a history of hypertension, developed central chest tightness. Upon paramedics’ arrival, she experienced ventricular fibrillation and required defibrillation twice, prior to regaining spontaneous circulation. She was transferred to her local hospital. ECG showed dynamic T-wave inversions in V2–V4. She was treated with standard ACS therapy and transferred to our tertiary centre for urgent cardiac catheterisation.
On arrival to the cathlab she was pain free and hemodynamically stable. Troponin T was elevated at 183 ng/l. Cardiac catheterization via transradial approach revealed normal epicardial coronary flow and minimal irregularities in the mid left anterior descending artery (LAD). The distal LAD was slightly tortuous ( Fig. 1 a and supplementary video clip 1). No obvious coronary abnormality, including no suggestion of SCAD, was evident to explain her presentation. Left ventricular systolic function was normal.
In view of her serious clinical presentation and lack of findings on coronary angiography, we decided to perform intracoronary imaging to the LAD using optical coherence tomography (OCT) (OPTIS Dragonfly®, St Jude, Abbott, MN, USA). OCT revealed a long segment of intramural hematoma (IMH) ( Fig. 1 b and supplementary video file 2). No intimal tear was seen. Unfortunately, attempts at repositioning the distal tip of the Asahi Soft (Asahi Intecc., Japan), a silicone coated, non-hydrophilic, workhorse wire, after OCT resulted in abrupt loss of flow in the distal LAD ( Fig. 2 a ). The patient developed chest pain and ST elevation. Following re-wiring of the vessel, a 2.5 × 10 mm Flextome® (Boston Scientific, Marlborough, USA) cutting balloon was inflated at low pressures (4–5 atm) in the mid to distal LAD to create fenestrations between the true and false lumen and relieve the intramural pressure. This improved flow and visualisation of the artery. The patient became pain free. A delayed angiographic imaging (20 min), showed restoration of flow distally with evidence of contrast hold-up at the distal tip of the LAD in the false lumen ( Fig. 2 b). Renal and iliac artery angiography was performed which showed no evidence of fibromuscular dysplasia. The patient had an uneventful recovery and was discharged on day 4. She was discharged on aspirin, clopidogrel, bisoprolol, and perindopril. The plan was to continue dual antiplatelet therapy for 1 year. She was totally asymptomatic and doing well at 30 day follow-up. Repeat angiography or computed tomography coronary imaging was not planned unless the patient had a recurrence of symptoms.
