Transcription
Hi, this is Manus Brilakis, and this is Case 116 for the manual of percutaneous coronary interventions. This is a case of spontaneous coronary artery dissection, illustrating some of the potential challenges when treating such patients.
The patient was a 42-year-old woman who presented with non-ST elevation myocardial infarction as well as ongoing chest discomfort. Access was obtained through the right radial artery, which may be an issue as we will discuss later on. Coronary angiography of the left system did not show any significant lesions. However, angiography of the right coronary artery demonstrated occlusion of the posterior descending artery. This seemed to be diffused and in a pattern that is characteristic of spontaneous coronary artery dissection. This is a type 2 SCAD with a long, diffuse, and smooth narrowing. This is actually a type 2B, as the narrowing goes all the way from the beginning of the PDA to the distal portion of the artery. Interestingly, the right coronary artery is the least likely to cause a spontaneous coronary artery dissection, but this was the culprit in our patient.
So what to do for such patients? It depends on their presentation. If they are clinically stable without high-risk anatomy, then conservative treatment is preferred. If they have a two-vessel dissection in the proximal segment or left main, then bypass is considered. But if they have ongoing ischemia or hemodynamic instability, then revascularization is needed with either PCI or coronary bypass graft surgery. And our patient was having ongoing chest discomfort; therefore, PCI was chosen as the modality of revascularization.
In such cases, wiring should be done with caution to prevent extending the dissection. Using a workhorse guide wire, and actually, fortunately, the wire easily advanced to the end of the PDA. Balloon angioplasty was done with a 2.0-millimeter balloon, and this actually restored the symmetry of flow to the PDA, demonstrating the area that the dissection was likely present at. We then placed a long 2.5 x 30-millimeter drug-eluting stent. It is important to cover both edges of the dissection to minimize milking and pushing the hematoma either proximally or distally. That provided a nice result with satisfactory flow in the PDA. However, engagement was challenging, and what we now have is a dissection of the proximal right coronary artery. This is potentially one of the reasons for preferring femoral access in patients with suspected spontaneous coronary dissection, because engagement may be easier in those patients, minimizing manipulations of the guide catheter and potentially preventing proximal dissections as happened in this patient. We had to put another stent in the proximal right coronary artery, and then that provided a nice result. There was some area of lesion which could have been migration of the hematoma more proximally. We debated whether to place an additional stent or use a cutting balloon to decompress it, but we decided to leave it as it did not appear to be compromising flow.
The patient did okay; however, she came back two weeks later with recurring angina. This is the coronary angiogram. That proximal segment of the artery here actually reached the nose, so we ended up placing an additional drug-eluting stent, and that provided a nice result.
So some lessons from this case: The first one is that in patients with SCAD, it is best to avoid intervention unless we have to. In this patient, we had to because she was having ongoing chest discomfort. When doing angiography, it is important to have a coaxial guide arrangement, and actually, femoral access may be preferred in those patients as it facilitates engagement and may help minimize manipulations of the guide catheter. PCI in this patient was complicated by proximal dissection that required placement of an additional drug-eluting stent in the proximal right coronary artery. And finally, after extending the culprit lesion in this patient, there was a proximal area with a mild lesion, possibly through movement of the hematoma, that we elected to leave. But actually, that led to stenosis two weeks later. So the lesson is that potentially covering completely the area of disease might help minimize recurrent events.
So, SCAD patients: These can be high-risk patients. Using extreme caution in how PCI is performed and doing it only when absolutely necessary is the best way to minimize complications and optimize outcomes. Thank you.