Images in cardiology. Successful coronary artery stenting for spontaneous coronary artery dissection

Intravascular ultrasound-guided coronary artery stenting for spontaneous coronary artery dissection in a case of acute myocardial infarction associated with vasospasm in a non-culprit coronary artery during the hospitalization

We report a case of spontaneous coronary artery dissection (SCAD) causing acute myocardial infarction, which was complicated by vasospastic angina (VA). The patient received intravenous administration of t-PA. Emergency coronary angiography demonstrated narrowing of the left anterior descending artery (LAD) due to SCAD. During hospitalization, the patient suffered chest pain, and ECG showed ST elevation in the inferior leads. Sublingual administration of nitroglycerin provided temporary remission. Coronary stent implantation was performed electively using intravascular ultrasound imaging. This is the first reported case of SCAD associated with vasospasm in a non-culprit coronary artery during the hospitalization.

Idiopathic spontaneous coronary artery dissection: incidence, diagnosis and treatment

BACKGROUND

Less is known about characteristics, treatment and follow-up of patients with spontaneous coronary artery dissection (SCAD) without associated pregnancy or underlying atherosclerosis.

METHODS

We reviewed 5054 consecutive coronary angiographies for SCAD in patients without atherosclerosis or associated pregnancy and performed follow-up angiography in eligible patients.

RESULTS

SCAD were assessed in five patients (mean age 44 +/- 8.7 years). Interestingly, all were premenopausal women. Three had no cardiovascular risk factors, whereas two were previous smokers and one had slightly elevated cholesterol levels. Clinical presentation was acute myocardial infarction in four cases and unstable angina pectoris in one of them. Dissection was localized in the left anterior descending artery (LAD) in three cases and in the first marginal branch of the left circumflex artery in two cases. Three patients were treated conservatively with antithrombotic therapy and beta-blocker, whereas in one patient rescue-PCI with stenting of the ostium of the LAD was performed after failed thrombolysis. The fifth woman with dissected proximal LAD underwent CABG. Follow-up angiographies after 5.9 +/- 4.4 months showed complete angiographic resolution of the dissection in the medically treated patients and a perfect angiographic result of the stented LAD. All patients were free of symptoms after a mean follow-up of 13 +/- 10 months.

CONCLUSIONS

Idiopathic SCAD is a rare cause of acute coronary syndrome in premenopausal women. In case of single vessel dissection and normal blood flow of the dissected vessel, medical treatment with aspirin, clopidogrel and beta-blockade leads to complete angiographic resolution within a few months.