Sealing spontaneous coronary artery dissection with bioresorbable vascular scaffold implantation: Data from the prospective “Registro Absorb Italiano” (RAI Registry)

Spontaneous Coronary Artery Dissection: An Updated Comprehensive Review

Spontaneous coronary artery dissection (SCAD) is defined as a non-iatrogenic, non-traumatic separation of the coronary artery wall, which has gained considerable recognition as an important cause of acute coronary syndrome. Despite the emerging evidence, it is still frequently missed and requires a high index of suspicion, as failure to accurately identify SCAD promptly could prove fatal. SCAD is most prevalent among middle-aged women, although it can also be found in men and postmenopausal women. Risk factors of SCAD include exogenous hormone use, physical and emotional stressors, pregnancy, and several inflammatory and connective tissue disorders. COVID-19 also contributes to the prevalence of SCAD. SCAD is classified into four main types based on the angiographic findings - type 1, type 2, type 3, and type 4. The gold standard for diagnosis is coronary angiography; however, intracardiac imaging is useful if diagnostic doubts persist. Despite the increasing recognition of this disease, there is a paucity in the guidelines on the management of SCAD. Management may be conservative, medical, or interventional. Cardiac rehabilitation is also necessary in the management of patients with SCAD. In light of the gaps in evidence, the authors aim to provide a comprehensive review of the existing literature, outlining the pathophysiology, classification, and, most importantly, the evidence and pitfalls circulating diagnosis, acute, and long-term management of SCAD.

Spontaneous Coronary Artery Dissection in a Female Patient With Acute Myocardial Infarction

Spontaneous coronary artery dissection (SCAD) is the formation of a false lumen within a vessel wall, with an accumulation of blood leading to vessel occlusion, mimicking symptoms of acute myocardial infarction (AMI). Here, we discuss the case of a middle-aged woman with STEMI who was found to have coronary artery dissection on coronary angiography during left heart catheterization. Clinicians should have a high suspicion of SCAD in young females presenting with AMI without traditional risk factors for coronary artery disease. Such patients should receive urgent angiography. Once the diagnosis is confirmed, there are no clear guidelines for treating AMI secondary to SCAD. Hemodynamically stable patients can be managed with the immediate initiation of antiplatelet therapy and beta-blockers. Thrombolytic therapy is avoided due to the risk of dissection and intramural hematoma. Coronary artery bypass graft (CABG) is indicated in patients with multiple vessel involvement or patients who have had a primary coronary intervention fail. Bioresorbable vascular scaffolds (BVS) may be a better option in STEMI or hemodynamic instability. However, current treatment strategies are based on expert opinion and a few case studies.

Spontaneous Coronary Artery Dissection: Mechanisms, Diagnosis and Management

Spontaneous coronary artery dissection (SCAD) is a relatively infrequent cause of acute coronary syndrome that usually affects young to middle-aged women. Mainly because of its low prevalence, until recently, most of the evidence on this condition was derived from case reports and small series. Over the last 5 years, more robust evidence has become available from larger retrospective and prospective cohorts of patients with SCAD. The increase in knowledge and recognition of this entity has led to the publication of expert consensus on both sides of the Atlantic. However, new data are continuously accumulating from larger cohorts of patients with SCAD, bringing new light to this little-understood condition. The aim of this article is to update the knowledge on SCAD, including new information from recent studies published since the consensus documents from the European Society of Cardiology and the American Heart Association.

Spontaneous coronary artery dissection: contemporary aspects of diagnosis and patient management

Spontaneous coronary artery dissection is an increasingly recognised cause of acute coronary syndromes, especially in young and middle-age women. Recognising its particularities and differences with atherosclerotic disease is central for appropriately identifying and approaching these patients. The authors review the current state of knowledge on spontaneous coronary artery dissection and provide practical recommendations for the diagnosis and management of this condition, both in the acute and convalescence phases.

Bioresorbable Scaffolds in Spontaneous Coronary Artery Dissection: Long-Term Follow-Up in 4 Patients

Spontaneous coronary artery dissection is a rare condition, and diagnosis and treatment are challenging among patients who present with acute coronary syndrome. Typically, the condition affects young females who have no underlying atherosclerotic disease. To date, few cases of bioresorbable scaffold implantation for the treatment of spontaneous coronary artery dissection have been reported. Therefore, we describe the cases of 4 patients whom we treated with scaffolds. We evaluated the long-term results by using intravascular ultrasound and optical coherence tomographic scanning.

Iatrogenic propagation of coronary dissection during diagnostic coronary angiography: an uncommon but important procedural consideration

Spontaneous coronary artery dissection is an uncommon cause of acute myocardial infarction in the general population but is relatively more common in the peripartum period. Regardless of clinical setting, the management strategy is individualised, ranging from conservative to invasive. We report a case of peripartum myocardial infarction due to spontaneous coronary dissection that propagated during diagnostic angiography and ultimately required emergent bypass surgery.

Pregnancy and the Risk of Spontaneous Coronary Artery Dissection: An Analysis of 120 Contemporary Cases

BACKGROUND

Because of the rarity of this condition, information on pregnancy-associated spontaneous coronary artery dissection is limited. We reviewed a large number of contemporary pregnancy-associated spontaneous coronary artery dissection cases in an attempt to define the clinical characteristics and provide management recommendations.

METHODS AND RESULTS

A literature search for cases of pregnancy-associated spontaneous coronary artery dissection reported between 2000 and 2015 included 120 cases; 75% presented with ST-segment-elevation myocardial infarction, and 80% had anterior myocardial infarction. Left anterior descending coronary artery was involved in 72% of cases, left main segment in 36%, and 40% had multivessel spontaneous coronary artery dissection. Ejection fraction was reduced to <40% in 44% of cases. Percutaneous coronary intervention was successful in only 50% of cases. Coronary artery bypass surgery was performed in 44 cases because of complex anatomy, hemodynamic instability, or failed percutaneous coronary intervention. Maternal complications included cardiogenic shock (24%), mechanical support (28%), urgent percutaneous coronary intervention (28%), urgent coronary artery bypass surgery (27.5%), maternal mortality (4%), and fetal mortality (2.5%). During follow-up for 305±111 days, there was a high incidence of symptoms because of persistent or new spontaneous coronary artery dissections, and 5 women needed heart transplantation or ventricular assist device implantation.

CONCLUSIONS

Pregnancy-associated spontaneous coronary artery dissection is commonly associated with left anterior descending, left main, and multivessel involvement, which leads to a high incidence of reduced ejection fraction, and life-threatening maternal and fetal complications. Percutaneous coronary intervention is associated with low success rate and high likelihood of complications, and coronary artery bypass surgery is often required. Recurrent ischemic events because of persistent or new spontaneous coronary artery dissection are common during long-term follow-up.

First reported case of magnesium-made bioresorbable scaffold to treat spontaneous left anterior descending coronary artery dissection

Spontaneous coronary artery dissection (SCAD) is a rare cause of Acute Coronary Syndrome. Although its treatment is still debated, use of Bioreasorbable Scaffold was recently advocated as an attractive option in this setting. We report the first case, to our knowledge, of a new magnesium-made Bioresorbable Scaffold implantation in a young woman presenting with Non-ST- Elevation Myocardial Infarction and a rapid worsening SCAD.

IVUS and OCT guided primary percutaneous coronary intervention for spontaneous coronary artery dissection with bioresorbable vascular scaffolds

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.