Primary stenting in acute myocardial infarction secondary to right coronary artery dissection following blunt chest trauma. Usefulness of intracoronary ultrasound

Spontaneous coronary artery dissection: new insights into diagnosis and treatment

Spontaneous coronary artery dissection (SCAD) remains an infrequent, elusive, and challenging clinical entity of unknown etiology eight decades after its initial description. Our understanding of the pathophysiology of SCAD, initially limited to information from early pathological studies, case reports, and very short series, has been enriched recently by relatively large contemporary series of patients studied prospectively. The typical presentation involves a young woman without coronary risk factors suffering an acute coronary syndrome but, actually, most patients are middle-aged and have coronary risk factors. A high number of conditions have been related to SCAD, but fibromuscular dysplasia has shown a major intriguing association with potential pathophysiological implications. SCAD may present (a) with an intimal tear and the classic angiographic 'flap' leading to the appearance of two lumens (true and false), or (b) without an intimal rupture, as an intramural hematoma. An increased clinical awareness together with new diagnostic tools have led to a major surge in the diagnosis of SCAD. High-resolution intracoronary techniques provide unique diagnostic insights into the underlying pathophysiology and facilitate identification of the disease in patients misdiagnosed previously. After the initial acute ischemic insult, most patients stabilize and have a benign clinical course and eventually experience spontaneous healing of the vessel wall during follow-up. However, recurrences may still occur in up to 10-20% of cases. Accordingly, a conservative medical management (watchful waiting strategy) has been recommended as the initial approach. Revascularization remains particularly challenging and may be associated with suboptimal results, acute complications, and poor long-term outcome. Nevertheless, in patients with ongoing or refractory ischemia and adequate anatomy, revascularization should be attempted. Some novel and attractive coronary interventions have been proposed in this uniquely challenging anatomic scenario. This review aims to present a comprehensive and contemporary update on this elusive and intriguing clinical entity.

Coronary Thrombosis without Dissection following Blunt Trauma

Blunt trauma to the chest resulting in coronary thrombosis and ST elevation myocardial infarction (STEMI) is a rare but well-described occurrence in adults. Angiography in such cases has generally disclosed complete epicardial coronary occlusion with thrombus, indistinguishable from the findings commonly found in spontaneous plaque rupture due to atherosclerotic disease. In all previously reported cases in which coronary interrogation with intravascular ultrasound (IVUS) was performed in association with acute revascularization, coronary artery dissection was implicated as the etiology of coronary thrombosis. We present the first case report of blunt trauma-associated coronary thrombosis without underlying atherosclerosis or coronary dissection, as documented by IVUS imaging.

Coronary artery dissection in a patient with traumatic femoral shaft fracture

We report a 24-year-old man who developed postoperative pulmonary edema and desaturation, after open reduction with internal fixation for left femoral shaft fracture sustained in a motorcycle accident. Cardiac catheterization revealed a left anterior descending coronary artery dissection. Review of his present history, showed that he neither had chest discomfort nor suffered from hemodynamic decompensation preoperatively. Only the abnormal 12-lead ECG with moderate tachycardia was suggestive of myocardial ischemia. Coronary artery dissection, although uncommon, is a disastrous complication following blunt chest trauma, and needs thorough preoperative evaluation to exclude its occurrence.

Traumatic coronary artery dissection: a case report and literature review

BACKGROUND

Coronary artery dissection after blunt chest trauma is a rare, life-threatening condition.

OBJECTIVES

To present a case of coronary artery dissection after blunt chest trauma and to outline the appropriate management of this condition based on a literature review.

CASE REPORT

We report the case of a 50-year-old woman with traumatic coronary artery dissection after a high-speed motor vehicle collision. She presented to the Emergency Department via ambulance within a few hours of the collision, and her clinical condition deteriorated rapidly. A 12-lead electrocardiogram on arrival demonstrated anterolateral ST-segment elevation. The patient was intubated due to hypoxemic respiratory failure and she required inotropes for blood pressure support. Computed tomography imaging revealed pulmonary edema and right third and fourth rib fractures. Emergent angiography demonstrated dissection of her left main coronary artery, requiring placement of a stent.

CONCLUSION

Early recognition of this clinical entity with a screening electrocardiogram, and aggressive management, may result in a favorable outcome. A literature review reveals that coronary artery bypass grafting, angiography with stent placement, and conservative management may all be considered viable treatment options for this condition.

Spontaneous resolution of an accidental total coronary occlusion

In December 2007, a woman was involved in a traffic accident. At first, her vital signs were normal, but electrocardiogram showed ST-segment elevation in the inferior leads. She was diagnosed as a blunt chest trauma-induced myocardial infarction. Her right coronary angiography showed total occlusion. She underwent an emergency coronary artery bypass surgery; 64-multi-detector-row computed tomography (64-MDCT) demonstrated an intravascular protruding lesion, which suggested subintimal hematoma. One month later, repeat coronary angiogram showed spontaneous recanalization, and 64-MDCT showed no discontinuous vessel wall. Coronary artery occlusion secondary to blunt chest trauma is rare, and it's even rarer to have spontaneous recanalization.

Aortic insufficiency due to a partial left-coronary aortic valve prolapse and the detection of two small interatrial jets after blunt thoracic trauma

Aortic valve regurgitation due to blunt thoracic trauma is a rare complication. Autopsy studies have been shown that the aortic valve is the most often lacerated one among the heart valves. Actually, we describe a case of a 47 year old man with the signs of heart failure after a blunt thoracic trauma 2 months before caused by aortic insufficiency due to a partial left-coronary aortic valve prolapse. Furthermore, transthoracic and transesophageal echocardiography revealed two small jets between the left and the right atrium.

Coronary artery dissection after blunt chest trauma: Depiction at multidetector-row computed tomography

Coronary artery dissection after blunt chest trauma has rarely been reported in traumatic cardiac injuries, but it may cause fatal or nonfatal myocardial infarction. We report a case of dissection of the left main coronary artery, which resulted in acute myocardial infarction 5 weeks after blunt chest trauma. Multidetector-row computed tomography performed prior to the onset of infarction depicted intimal flap and dissected cavities.

Blunt traumatic dissection of the proximal left anterior descending artery

Coronary artery dissection secondary to blunt chest trauma is a rare occurrence recently reported in the Emergency Medicine Journal. The case here is reported of a left anterior descending artery dissection after blunt chest trauma to illustrate a different, more precipitous presentation of this condition after severe trauma. This case report highlights how clinical history can alert to the presence of this complication and how electrocardiography is fundamental to risk stratification after trauma, and discusses management alternatives for this condition in the setting of multi-trauma.