Coronary angioplasty in spontaneous coronary artery dissection—Strategy and outcomes

Abstract

Objective To study the clinical, angiographic and technical characteristics of patients with spontaneous coronary artery dissection (SCAD) undergoing percutaneous coronary intervention (PCI). Methods This was a retrospective single center study where patients with angiographically confirmed SCAD undergoing PCI over a period of 4 years (2013–2017) were analyzed. We also sought to identify the clinical and angiographic predictors of procedural failure during PCI. Results There were a total of 42 patients with angiographically confirmed SCAD during the study period of which 16 patients (38.1%) underwent PCI. 14 out of the 16 patients (87.5%) taken up for PCI had technical success. In all patients the lesion was initially attempted to cross with a floppy wire and if unsuccessful it was escalated to a hydrophilic wire and finally to a stiff wire The SCAD lesion was crossed with a floppy wire in 71.4% of patients, with a hydrophilic wire in 14.2% and a stiff wire in 7.1% of patients. Wire escalation was required in 5 patients (31.3%) and in 60% of cases there was a technical success after wire escalation. Presence of diabetes mellitus, hypertension, dyslipidemia, smoking, coexisting atherosclerosis, diffuse nature of the lesion, and baseline Thrombolysis in Myocardial Infarction (TIMI) ≤ 2 flow did not predict procedural failure during PCI. Conclusion PCI in SCAD is associated with a fair rate of technical success in our population. Choosing an initial floppy wire and then escalating to a hydrophilic wire followed by a stiff wire is an optimal revascularization strategy.

A Complex Case of Pregnancy-related Left Main Stem Spontaneous Coronary Artery Dissection

“…The use of cutting balloons to decompress IMH and restore flow has been well described, but this strategy has been largely adopted prior to drug-eluting stent placement. [ 5 – 7 ] We demonstrate the ability for this technology to improve coronary flow in extensive SCAD as a bridge to cardiac surgery. It is vital that imaging be used in such cases to confirm luminal placement of coronary wires and assess the extent of dissection/haematoma.…”

“…Previous studies have demonstrated a 71.4% success rate of such techniques and reserving escalation to hydrophilic wires for cases in which luminal guidewire placement is not possible. [ 5 ]…”

Surgical Management of Type A Aortic Dissection After Percutaneous Coronary Intervention in a Patient with Acute Myocardial Infarction Due to a Spontaneous Coronary Artery Dissection

“…Forced and intense injection of the contrast medium must be avoided. (4,5) Although rare, iatrogenic retrograde extension of the dissection into the ascending aorta (0,02 -0,6% of diagnostic and interventional percutaneous procedures) is reported. (6) Dunning et al have found a significantly increased rate in aortocoronary dissections in procedures performed for acute myocardial infarction (AMI) (0,19%) compared with non-AMI cases (0,01%).…”

Update in Spontaneous Coronary Artery Dissection

“…In the acute setting, the stent may appear to be well-apposed to the wall but in time as the dissection heals and the hemorrhage resorbs, the stent may well be significantly undersized and malapposed, which predisposes the patient towards repeat revascularization and other catastrophic outcomes like stent thrombosis and its attendant complications. Strategies for successful percutaneous intervention in SCAD patients have been described and include interventional wires selection strategies [ 25 ], use of OCT imaging identify and seal the dissection flap with spot stenting [ 26 ], a multistent strategy with IVUS guidance to place stents proximal and distal to the lesion to prevent medial hemorrhage propagation [ 27 ]. Detailed technical recommendations of PCI techniques to mitigate risk of failure are beyond the scope of this review.…”