A 47-year-old woman with a history of multiple previous spontaneous coronary artery dissection (SCAD) episodes, treated both conservatively and with percutaneous coronary intervention (PCI), was referred for coronary angiography due to atypical chest pain. The purpose of the exam was to reassess coronary anatomy and exclude recurrent dissection or ischemia-related stenosis. Angiography showed an optimal result of the prior left anterior descending (LAD) stenting and complete healing of the distal right coronary artery (RCA), previously involved in her last event. However, during a final control injection, a large iatrogenic dissection occurred, extending from the left main (LM) into both the LAD and left circumflex (LCx). True lumen wiring of both vessels was achieved, followed by OCT-guided stenting, leading to full hemodynamic stabilization. This case highlights the potential risks associated with invasive assessment in SCAD patients, emphasizing the importance of careful procedural planning. Noninvasive follow-up (e.g., CCTA) should be considered whenever feasible, and operators must remain prepared to manage potential severe complications during the procedure.
Spontaneous coronary artery dissection (SCAD) is an increasingly recognized cause of acute coronary syndrome (ACS). Predominantly identified in middle-aged women, recent evidence highlights SCAD as the underlying etiology in up to 35% of all events in females under 50 of age. ,
SCAD is characterized by the nonatherosclerotic, nontraumatic development of an intramural hematoma (IMH) within the tunica media of an epicardial coronary artery. , The expansion of this IMH can lead to compression and occlusion of the vessel’s true lumen, occasionally associated with an intimal tear and subsequent thrombus formation.
This underlying etiology underscores the importance of regarding SCAD as sentinel marker for systemic arteriopathy. Accordingly, current expert consensus statements strongly advocate for a conservative management strategy in hemodynamically stable patients without ongoing ischemia.
Conversely, in patients presenting with total vessel occlusion, refractory ischemia, malignant arrhythmias, or hemodynamic compromise, urgent revascularization to restore coronary flow must be considered. The decision to perform percutaneous coronary intervention (PCI) in the SCAD setting is undoubtely one of the most formidable challenges in the catheterization laboratory. These procedures are fraught with risk, primarily due to the heightened susceptibility to iatrogenic injury during intracoronary manipulation and the danger of antegrade or retrograde hematoma propagation, both of which can lead to a catastrophic loss of coronary patency.
We report the case of a 47-year-old woman with a history of recurrent multivessel SCAD. Her initial presentation occurred in 2010, when she arrived at the emergency department (ED) with an electrocardiogram demonstrating ST-segment elevation in the anterior leads. Coronary angiography revealed multivessel involvement: a Type 2a SCAD in the proxymal right coronary artery (RCA) and a Type 2b SCAD on the mid and distal left anterior descending artery (LAD). Both vessels were successfully treated with direct stenting using bare metal stents (BMS). Specifically, 2 BMS were implanted in the mid and distal LAD, effectively sealing the proximal and distal margins of the IMH ( Figure 1 ). The patient was subsequently discharged without complications; her echocardiogram showed a left ventricular ejection fraction of 45% with localized apical hypokinesis.
Clinical history and SCAD evolution (2010–2020). (A) First Event (2010): Invasive coronary angiography (ICA) demonstrating multivessel involvement with a Type 2a SCAD in the proximal right coronary artery (RCA) and a Type 2b SCAD in the left anterior descending artery (LAD). Both vessels were successfully treated with direct stenting (1 BMS in the RCA and 2 BMS in the mid and distal LAD). (B) Second Event (2020): ICA revealing a new Type 2b SCAD involving the distal posterolateral (PL) branch of the RCA. This event was managed conservatively with single antiplatelet therapy (SAPT), which resulted in complete vascular healing as confirmed by subsequent imaging.
The second event occurred in 2020, when the patient presented to our institution with chest pain and elevated high-sensitive troponin, a clinical presentation consistent with a non-ST-segment elevation myocardial infarction (NSTEMI). Coronary angiography identified an IMH (Type 2° SCAD) involving the distal posterlateral (PL) branch of the RCA. Given the patient’s clinical and hemodynamic stability, the low prognostic significance of the coronary segment involved and the absence of ongoing ischemia, our team opted for a conservative strategy ( Figure 1 ). She was subsequently discharged on single antiplatelet therapy (SAPT). At the time, an initial screening for fibromuscular dysplasia (FMD) was performed via abdominal CT angiography and brain magnetic resonance imaging, both of which were negative.
In 2023, the patient returned to the emergency department reporting a new onset of chest pain. Although she noted the symptoms were qualitatively different from her previous episodes, her history of recurrent multivessel SCAD mandated a high level of clinical vigilance. Despite an unremarkable electrocardiogram and no significant elevation in cardiac biomarkers, the suspicion of unstable angina could not be definitively ruled out given the patient’s high-risk profile. Consequently, the medical team elected to proceed with prompt diagnostic coronary angiography.
Cath Lab and Technical Insights: The Interventionalist Perspective
The procedure was performed via 6F right radial access. Initial angiography of the RCA demonstrated complete vascular healing of the PL ( Video 1 , Figure 1 ), validating the conservative management adopted for 2020 NSTEMI. Subsequent engagement of the left coronary artery system confirmed the long-term patency and integrity of the LAD stents ( Video 2 ). With no significant obstructive disease or recurrent SCAD identified in the entire coronary tree, the clinical suspicion shifted from unstable angina toward noncardiac, atypical chest pain.
The complication arose during a standard fluoroscopic check while exchanging the JL 3.5 6F diagnostic catheter. An extensive and persistent contrast stain became visible, involving both the LAD and the left circumflex (LCx), coinciding with the acute onset of severe chest pain ( Video 3 ). It became immediately apparent that a catastrophic iatrogenic dissection had occurred. At this juncture, the indication for emergency PCI was absolute, necessitating rapid and precise strategic planning.
The presence of the previously implanted stents in the midto-distal LAD served as a critical landmark, effectively sealing the distal portion of the vessel and facilitating successful guidewire positioning within the true lumen ( Figure 2 , Video 4 ). Prioritizing the restoration of flow in the LAD—the largest and most prognostically significant vessel—enhanced hemodynamic stability and overall procedural safety. This stepwise approach provided the necessary clinical confidence to address the LCx wiring and the complex bifurcation injury with greater precision.
Strategic revascularization planning. Leveraging the specific anatomy encountered during the procedure: the presence of previously implanted stents in the mid-to-distal LAD acted as a mechanical barrier, effectively sealing the distal segment and facilitating guidewire positioning within the true lumen. Prioritizing flow restoration in the LAD—the largest and most prognostically significant vessel—ensured greater procedural safety and hemodynamic stability during the complex management of the iatrogenic dissection.
Wiring the true lumen of the LCx proved more arduous, requiring multiple attempts. The technical resolution of this phase was particularly noteworthy and of significant interest to the interventional community. Fluoroscopic imaging captured a critical finding: a large dissection flap in the proximal segment of the first obtuse marginal (OM1) branch had completely occluded the vessel, resulting in significant contrast staining and obstructing guidewire passage. During repeated wiring maneuvers, a “live” puncture of the IMH was documented. This accidental fenestration led to immediate decompression of the hematoma, evidenced by the sudden clearance of the contrast stain and subsequent opacification of the distal true lumen ( Figure 3 , Video 5 ).
