Summary
Spontaneous coronary artery dissection (SCAD) is an uncommon but important cause of acute coronary syndrome. The diagnosis of SCAD by an angiogram alone can be challenging and the increasing use of intracoronary imaging has proven an invaluable diagnostic adjunct in this regard. The appropriate initial management of SCAD has been a matter of significant debate. Owing to frequent spontaneous healing of coronary dissection and a higher risk of complications with percutaneous coronary intervention (PCI) in the setting of SCAD, a default approach of mechanical revascularization is not recommended. However in the presence of vessel occlusion and on-going myocardial infarction PCI is mandated. Bioresorbable vascular scaffolds (BVS) offer potential advantages over the conventional stents in the setting of SCAD. We describe a state-of-the-art approach to the acute treatment of SCAD causing STEMI, utilizing intravascular ultrasound (IVUS), optical coherence tomography (OCT) and BVS and discuss management strategies for the modern era.
Highlights
- •
SCAD is an infrequent but important cause of acute coronary syndrome.
- •
Intracoronary imaging is a useful adjunct in the diagnosis of SCAD.
- •
Revascularization is recommended in the presence on-going myocardial infarction.
- •
BVS may be considered preferable to conventional stents in the setting of SCAD.
1
Introduction
Acute ST-segment elevation myocardial infarction (STEMI) is uncommon in a young female patient without risk factors for coronary artery disease. In such patients, a wider differential diagnosis should be considered, which should include spontaneous coronary artery dissection (SCAD). SCAD can be challenging to treat percutaneously, although in the presence of vessel occlusion and on-going myocardial infarction percutaneous coronary intervention (PCI) is mandated.
We describe a state-of-the-art approach to the acute treatment of SCAD causing STEMI, utilizing intravascular ultrasound (IVUS), optical coherence tomography (OCT) and bioresorbable vascular scaffolds (BVS), and discuss management strategies for the modern era.
2
Case description
A 42-year-old woman was admitted with anterior ST-segment elevation myocardial infarction (STEMI). She had been carrying chairs at her place of work prior to the onset of severe chest pain. She had no history of smoking or illicit drug use and had no significant past medical history. Clinical examination was normal. Her electrocardiogram showed marked ST-elevation in leads I, II, aVL, and V4–V6. She was transferred from the community directly to the catheter lab with a view to primary percutaneous coronary intervention (PPCI).
A coronary angiogram from the right radial artery showed occlusion of left anterior descending artery (LAD) with thrombolysis in myocardial infarction (TIMI) flow grade 0 ( Fig. 1 ). Other coronary arteries were normal.
