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==Overview==
==Overview==
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Difficulties can be present when assessing the [[angiographic]] residual [[lumen]] in the presence of [[coronary]] dissection due to the frame-to-frame [[lumen]] diameter changes using two-dimensional imaging; [[intravascular ultrasound]] ([[IVUS]]) may be more accurate strategy to provide the true circumference [[lumen]] dimensions.
Difficulties can be present when assessing the [[angiographic]] residual [[lumen]] in the presence of [[coronary]] dissection due to the frame-to-frame [[lumen]] diameter changes using two-dimensional imaging; [[intravascular ultrasound]] ([[IVUS]]) may be more accurate strategy to provide the true circumference [[lumen]] dimensions.


In the [[NHLBI]] scheme, dissection is defined as an [[lumen|intraluminal]] filling defect or flap associated with a hazy, ground-glass appearance. This category is sub-classified using the [[NHLBI]] ([[NHLBI|National Heart Lung and Blood Institute]]) system for grading dissection types:
In the [[NHLBI]] scheme, dissection is defined as an [[lumen|intraluminal]] filling defect or flap associated with a hazy, ground-glass appearance. This category is sub-classified using the [[NHLBI]] ([[NHLBI|National Heart Lung and Blood Institute]]) system for grading dissection types:<ref name="Huber-1991">{{Cite journal  | last1 = Huber | first1 = MS. | last2 = Mooney | first2 = JF. | last3 = Madison | first3 = J. | last4 = Mooney | first4 = MR. | title = Use of a morphologic classification to predict clinical outcome after dissection from coronary angioplasty. | journal = Am J Cardiol | volume = 68 | issue = 5 | pages = 467-71 | month = Aug | year = 1991 | doi =  | PMID = 1872273 }}</ref>


===Type A===
===Type A===
[[Dissection: Type A | Radiolucent areas]] within the coronary lumen during contrast injection, with minimal or no persistence of contrast after dye has cleared.
 
* Type A dissections represent radiolucent areas within the [[coronary]] [[lumen]] during [[contrast]] [[injection]], with minimal or no persistence of [[contrast]] after [[dye]] has cleared.


===Type B===
===Type B===


[[Dissection: Type B | Parallel tracts]] or double lumen separated by a radiolucent area during contrast injection, with minimal or no persistence after dye has cleared.
* Type B dissections are parallel tracts or double [[lumen]] separated by a radiolucent area during [[contrast]] [[injection]], with minimal or no persistence after [[dye]] clearance.


===Type C===
===Type C===


[[Dissection: Type C | Contrast outside the coronary lumen]], with persistence of contrast in the area after dye has cleared.
* Type C dissections appear angiographically as [[contrast]] outside the coronary lumen ("extraluminal cap") with persistence of [[contrast]] in the area after clearance of [[dye]] from the coronary lumen.


===Type D===
===Type D===


[[Dissection: Type D | Spiral luminal filling]] defects frequently with extensive contrast staining of the vessel.
* Type D dissections represent spiral ("barber shop pole") luminal filling defects, frequently with extensive [[contrast]] staining of the [[vessel]].
 
''Shown below are an animated image and a static image depicting coronary artery dissection type D.  Outlined in yellow is the spiral luminal filling defect that characterizes type D coronary artery dissection.''
 
[[Image:Spiral dissection.gif|300px]]
[[Image:Dissection spiral-static.gif|300px]]


===Type E===
===Type E===


[[Dissection: Type E | New persistent filling defects]] that may be caused by [[thrombus]].
* Type E dissections appear as new, persistent filling defects.
* As proposed by the Coronary Angioplasty Registry, type E dissection may be caused by [[thrombus]].


===Type F===
===Type F===


These are [[Dissection: Type F | non A – E dissection types]] that lead to impaired flow or total occlusion of the coronary artery.
* Type F dissections represent those that lead to total [[occlusion]] of the [[coronary artery]], without distal anterograde flow.
* As proposed by the Coronary Angioplasty Registry, type F dissection may be caused by [[thrombus]].
 
=====Other Associated Definitions/Terms=====


Other associated definitions / terms include the following:
* ''Abrupt closure:'' Obstruction of [[contrast]] flow ([[TIMI]] 0 or [[TIMI 1|1]]) in a dilated segment with previously documented anterograde flow
* ''Abrupt closure:'' Obstruction of contrast flow (TIMI 0 or 1) in a dilated segment with previously documented anterograde flow
* ''Ectasia:'' A [[lesion]] diameter greater than the reference diameter in one or more areas
* ''Ectasia:'' A lesion diameter greater than the reference diameter in one or more areas
* ''[[lumen|Luminal]] irregularities:'' [[artery|Arterial]] contour that has a “sawtooth pattern” consisting of opacification but not fulfilling the criteria for dissection or intracoronary [[thrombus]]
* ''Luminal irregularities:'' Arterial contour that has a “sawtooth pattern” consisting of opacification but not fulfilling the criteria for dissection or intracoronary thrombus
* ''[[Intima]]l flap:'' A discrete filling defect in apparent continuity with the [[artery|arterial]] wall
* ''Intimal flap:'' A discrete filling defect in apparent continuity with the arterial wall
* ''[[Thrombus]]:'' Discrete, mobile [[angiographic]] filling defect with or without [[contrast]] staining
* ''Thrombus:'' Discrete, mobile angiographic filling defect with or without contrast staining
* ''Length:''Measure end-to-end for type B through F dissections
* ''Length:''Measure end-to-end for type B through F dissections
* ''Staining:'' Persistence of contrast within the dissection after washout of contrast from the remaining portion of the vessel'''
* ''Staining:'' Persistence of [[contrast]] within the dissection after washout of [[contrast]] from the remaining portion of the [[vessel]]
* ''Perforation Localized:'' Extravasation of contrast confined to the pericardial space immediately surrounding the artery and not associated with clinical tamponade
* ''Perforation Localized:'' [[Extravasation]] of [[contrast]] confined to the [[pericardial space]] immediately surrounding the [[artery]] and not associated with clinical [[tamponade]]
* ''Nonlocalized perforation:'' Extravasation of contrast with a jet not localized to the pericardial space, potentially associated with clinical tamponade
* ''Nonlocalized perforation:'' [[Extravasation]] of [[contrast]] with a jet not localized to the [[pericardial space]], potentially associated with clinical [[tamponade]]
* ''Side branch loss:'' TIMI 0, 1, or 2 flow in a side branch > 1.5 mm in diameter which previously had TIMI 3 flow
* ''Side branch loss:'' [[TIMI flow grade 0|0]], [[TIMI 1|1]], or [[TIMI flow grade 2|2]] flow in a side branch > 1.5 mm in diameter which previously had [[TIMI flow grade 3|TIMI 3 flow]]
* ''Distal embolization:'' Migration of a filling defect or thrombus to distally occlude the target vessel or one of its branches
* ''[[Distal]] [[embolus|embolization]]:'' Migration of a filling defect or [[thrombus]] to [[distal]]ly occlude the target [[vessel]] or one of its branches
* ''Coronary spasm:'' Transient or permanent narrowing >50% when a <25% stenosis was previously noted
* ''[[Coronary spasm]]:'' Transient or permanent narrowing >50% when a <25% [[stenosis]] was previously noted


==Pathophysiology==
==Pathophysiology==
The two primary mechanisms accounting for disruption of the coronary vessel wall include barotrauma and guiding catheter dissections. Most coronary dissections occur as a result of percutaneous coronary intervention, but they may also occur either as an extension of an aortic dissection into the [[right coronary artery]], or in the setting of [[coronary bypass grafting]]. Spontaneous coronary dissection in the coronary artery is itself rare.
The two primary mechanisms accounting for disruption of the [[coronary]] [[vessel]] wall include [[barotrauma]] and guiding catheter dissections. Most [[coronary]] dissections occur as a result of percutaneous coronary intervention, but they may also occur either as an extension of an [[aortic dissection]] into the [[right coronary artery]], or in the setting of [[coronary bypass grafting]]. [[Spontaneous coronary artery dissection]] is itself rare.
===Histopathological Findings===
 
==Histopathological Findings==
[http://www.peir.net Images courtesy of Professor Peter Anderson DVM PhD and published with permission © PEIR, University of Alabama at Birmingham, Department of Pathology]
[http://www.peir.net Images courtesy of Professor Peter Anderson DVM PhD and published with permission © PEIR, University of Alabama at Birmingham, Department of Pathology]


<gallery perRow="3">
<gallery perRow="3">
Image:Traumatic coronary artery dissection 002.jpg|Coronary artery: Dissection Secondary to Trauma: Micro low mag H&E large adventitial hemorrhage this is a diagonal branch of the left anterior descending artery caused massive infarct
Image:Traumatic coronary artery dissection 002.jpg|[[Coronary artery]]: Dissection Secondary to Trauma: Micro low mag H&E large [[tunica adventitia|adventitial]] [[hemorrhage]] this is a [[diagonal branch]] of the [[LAD|left anterior descending artery]] caused massive [[infarct]]
Image:Traumatic coronary artery dissection 003.jpg|Coronary artery: Dissection Secondary to Trauma: Micro low mag H&E completely occluded LAD
Image:Traumatic coronary artery dissection 003.jpg|[[Coronary artery]]: Dissection Secondary to Trauma: Micro low mag H&E completely occluded [[LAD]]
</gallery>
</gallery>


===Spontaneous coronary artery dissection (SCAD)===
==Treatment==
The majority of dissections occur following [[percutaneous coronary intervention]] (PCI). However, although rare, coronary dissections can occur spontaneously. The literature is sparse with only approximately 300 documented cases of spontaneous dissection.<ref name="pmid18830003">{{cite journal |author=Kamran M, Guptan A, Bogal M |title=Spontaneous coronary artery dissection: case series and review |journal=J Invasive Cardiol |volume=20 |issue=10 |pages=553–9 |year=2008 |month=October |pmid=18830003 |doi= |url=http://jic.epubxpress.com/link/jic/2008/oct/90?s=0}}</ref>
[[Coronary]] [[stent]] placement, [[surgery]] and [[anticoagulation]] would appear to be reasonable treatment modalities.<ref>{{cite journal |author=Narasimhan, S |title=Spontaneous coronary artery dissection (SCAD)|journal=IJTCVS |volume=20 |issue=4 |pages=189-91 |year=2004 |pmid= |doi= 10.1007/s12055-004-0084-x|url=http://medind.nic.in/ibq/t04/i4/ibqt04i4p189.pdf}}</ref> Given the rare nature of the disease, [[randomized control trial|randomized trial]] data is obviously lacking. Most intra-procedural dissections can be treated promptly with [[stent]]ing.
 
==Epidemiology and Demographics==
The incidence of SCAD in angiographic series is between 0.28 and 1.1%, and most 60% of the time the dissection occurs in the [[left anterior descending artery]] (LAD). <ref name="pmid18830003">{{cite journal |author=Kamran M, Guptan A, Bogal M |title=Spontaneous coronary artery dissection: case series and review |journal=J Invasive Cardiol |volume=20 |issue=10 |pages=553–9 |year=2008 |month=October |pmid=18830003 |doi= |url=http://jic.epubxpress.com/link/jic/2008/oct/90?s=0}}</ref> 80% of SCAD cases occur in young women, with those taking [[birth control]] medication or in the peripartum period at particular risk. <ref>{{cite journal |author=Narasimhan, S |title=Spontaneous coronary artery dissection (SCAD)|journal=IJTCVS |volume=20 |issue=4 |pages=189-91 |year=2004 |pmid= |doi= 10.1007/s12055-004-0084-x|url=http://medind.nic.in/ibq/t04/i4/ibqt04i4p189.pdf}}</ref>


==Risk Factors==
==Angiography==
It has been hypothesized that the strain of childbirth and the release of systemic factors such as [[relaxin]] underly the increased risk.  Other factors that may be involved include changes in hormones and autoimmune status as well as hemodynamic stress<ref name="pmid19127318">{{cite journal |author=Van den Branden BJ, Bruggeling WA, Corbeij HM, Dunselman PH |title=Spontaneous coronary artery dissection in the postpartum period |journal=Neth Heart J |volume=16 |issue=12 |pages=412–4 |year=2008 |month=December |pmid=19127318 |pmc=2612109 |doi= |url=}}</ref>. SCAD has also been found in patients with [[atherosclerosis]], [[connective tissue disorder]]s. <ref name="pmid18958258">{{cite journal |author=Tanis W, Stella PR, Kirkels JH, Pijlman AH, Peters RH, de Man FH |title=Spontaneous coronary artery dissection: current insights and therapy |journal=Neth Heart J |volume=16 |issue=10 |pages=344–9 |year=2008 |month=October |pmid=18958258 |pmc=2570766 |doi= |url=}}</ref> and [[bicuspid aortic stenosis]]<ref>Archives of cardiovascular diseases. Volume 102, n° 12 pages 857-858 (décembre 2009).</ref>
Click '''[[Coronary angiography dissection|here]]''' to view angiography examples of the different types of coronary artery dissection.
==Natural History, Complications and Prognosis==
The fact that the diagnosis was made so often in the past on autopsy speaks to the poor clinical outcomes that have been associated with the condition. Outcomes in the modern era of [[stent]] placement and improved [[antithrombin]]s may be improved, but solid data are lacking.
==Diagnosis==
The symptoms of SCAD mimic other [[acute coronary syndromes]]. In the past, this disorder was often diagnosed only at the time of [[autopsy]].<ref>{{cite journal |author=Narasimhan, S |title=Spontaneous coronary artery dissection (SCAD)|journal=IJTCVS |volume=20 |issue=4 |pages=189-91 |year=2004 |pmid= |doi= 10.1007/s12055-004-0084-x|url=http://medind.nic.in/ibq/t04/i4/ibqt04i4p189.pdf}}</ref>  At present, however, [[angiography]] is most often used to diagnose SCAD, although [[intravascular ultrasound]] and [[CT angiography]] are also used.<ref name="pmid18830003">{{cite journal |author=Kamran M, Guptan A, Bogal M |title=Spontaneous coronary artery dissection: case series and review |journal=J Invasive Cardiol |volume=20 |issue=10 |pages=553–9 |year=2008 |month=October |pmid=18830003 |doi= |url=http://jic.epubxpress.com/link/jic/2008/oct/90?s=0}}</ref>
==Treatment==
Coronary stent placement, surgery and anticoagulation would appear to be reasonable treatment modalities. <ref>{{cite journal |author=Narasimhan, S |title=Spontaneous coronary artery dissection (SCAD)|journal=IJTCVS |volume=20 |issue=4 |pages=189-91 |year=2004 |pmid= |doi= 10.1007/s12055-004-0084-x|url=http://medind.nic.in/ibq/t04/i4/ibqt04i4p189.pdf}}</ref>. Given the rare nature of the disease, randomized trial data is obviously lacking. Most intra-procedural dissections can be treated promptly with stenting.


==References==
==References==

Latest revision as of 04:11, 2 April 2014

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [2], Vanessa Cherniauskas, M.D. [3]

Overview

A coronary artery dissection refers to a split or a tear in the wall of the artery which compresses or compromises the lumen of the artery reducing blood flow. Coronary artery dissection occurs rarely in the absence of percutaneous coronary intervention (PCI). The risk of reduced anterograde flow and lumen narrowing is a relatively (< 3%) uncommon complication of PCI. Significant residual dissections are present in approximately 1.7 % of patients undergoing PCI.[1] Intracoronary stent placement is used to stabilize the dissection.

Classification

The National Heart, Lung and Blood Institute (NHLBI) coronary dissection criteria assign according the severity of coronary dissection following PCI, with the prognostic implications of the coronary dissection depending on extension into the media and adventitia, its axial length, presence of contrast staining, and effect on anterograde coronary perfusion.

Difficulties can be present when assessing the angiographic residual lumen in the presence of coronary dissection due to the frame-to-frame lumen diameter changes using two-dimensional imaging; intravascular ultrasound (IVUS) may be more accurate strategy to provide the true circumference lumen dimensions.

In the NHLBI scheme, dissection is defined as an intraluminal filling defect or flap associated with a hazy, ground-glass appearance. This category is sub-classified using the NHLBI (National Heart Lung and Blood Institute) system for grading dissection types:[2]

Type A

Type B

  • Type B dissections are parallel tracts or double lumen separated by a radiolucent area during contrast injection, with minimal or no persistence after dye clearance.

Type C

  • Type C dissections appear angiographically as contrast outside the coronary lumen ("extraluminal cap") with persistence of contrast in the area after clearance of dye from the coronary lumen.

Type D

  • Type D dissections represent spiral ("barber shop pole") luminal filling defects, frequently with extensive contrast staining of the vessel.

Shown below are an animated image and a static image depicting coronary artery dissection type D. Outlined in yellow is the spiral luminal filling defect that characterizes type D coronary artery dissection.

Type E

  • Type E dissections appear as new, persistent filling defects.
  • As proposed by the Coronary Angioplasty Registry, type E dissection may be caused by thrombus.

Type F

  • Type F dissections represent those that lead to total occlusion of the coronary artery, without distal anterograde flow.
  • As proposed by the Coronary Angioplasty Registry, type F dissection may be caused by thrombus.
Other Associated Definitions/Terms

Pathophysiology

The two primary mechanisms accounting for disruption of the coronary vessel wall include barotrauma and guiding catheter dissections. Most coronary dissections occur as a result of percutaneous coronary intervention, but they may also occur either as an extension of an aortic dissection into the right coronary artery, or in the setting of coronary bypass grafting. Spontaneous coronary artery dissection is itself rare.

Histopathological Findings

Images courtesy of Professor Peter Anderson DVM PhD and published with permission © PEIR, University of Alabama at Birmingham, Department of Pathology

Treatment

Coronary stent placement, surgery and anticoagulation would appear to be reasonable treatment modalities.[3] Given the rare nature of the disease, randomized trial data is obviously lacking. Most intra-procedural dissections can be treated promptly with stenting.

Angiography

Click here to view angiography examples of the different types of coronary artery dissection.

References

  1. Laskey WK, Williams DO, Vlachos HA; et al. (2001). "Changes in the practice of percutaneous coronary intervention: a comparison of enrollment waves in the National Heart, Lung, and Blood Institute (NHLBI) Dynamic Registry". Am. J. Cardiol. 87 (8): 964–9, A3–4. PMID 11305987. Unknown parameter |month= ignored (help)
  2. Huber, MS.; Mooney, JF.; Madison, J.; Mooney, MR. (1991). "Use of a morphologic classification to predict clinical outcome after dissection from coronary angioplasty". Am J Cardiol. 68 (5): 467–71. PMID 1872273. Unknown parameter |month= ignored (help)
  3. Narasimhan, S (2004). "Spontaneous coronary artery dissection (SCAD)" (PDF). IJTCVS. 20 (4): 189–91. doi:10.1007/s12055-004-0084-x.

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