Spontaneous coronary artery dissection percutaneous coronary intervention

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Spontaneous Coronary Artery Dissection Microchapters

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Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differentiating Spontaneous coronary artery dissection from other Diseases

Epidemiology and Demographics

Risk Factors

Screening

Natural History, Complications and Prognosis

Diagnosis

Diagnostic Approach

History and Symptoms

Physical Examination

Laboratory Findings

Electrocardiogram

Angiography

CT

MRI

Echocardiography

Other Imaging Findings

Other Diagnostic Studies

Treatment

Treatment Approach

Medical Therapy

Percutaneous Coronary Intervention

Surgery

Primary Prevention

Secondary Prevention

Cost-Effectiveness of Therapy

Future or Investigational Therapies

Case Studies

Type 1

Type 2A

Type 2B

Type 3

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Nate Michalak, B.A.

Synonyms and keywords: SCAD

Overview

Percutaneous Coronary Intervention

PCI is indicated in the presence of ongoing myocardial ischemia or myocardial infarction.[1] Drug eluting stents (DES) are routinely used in the management of SCAD. However, their impact on long-term outcomes has not been assessed yet in clinical studies.

Challenges and Suggestions With SCAD PCI
Challenges during PCI of SCAD
  • Risk of iatrogenic catheter-induced dissection
  • Difficulty advancing coronary wire into distal true lumen
  • Propagating IMH anterograde and retrograde with angioplasty/ stenting, extending dissection and further compromising true lumen arterial flow
  • Dissection tends to extend into distal arteries, which are too small for stents
  • Often extensive dissected segments require long stents, increasing stent restenosis
  • Risk of stent malapposition after resorption of IMH, with risk of late stent thrombosis
Suggestions if PCI is pursued for SCAD
  • Meticulous guide catheter manipulation, preferably through femoral access approach
  • OCT/IVUS guidance to ensure wire in true lumen (or over-the-wire catheter injections) and optimize stent apposition
  • Long stents covering 5-10 mm of proximal and distal edges of IMH
  • Placing short stents at proximal and distal edges first, before placing long stent in the middle
  • Consider bioabsorbable stents (temporary scaffold to avoid longterm malapposition)
  • Possible and careful use of cutting balloon (to fenestrate IMH)
  • Consider follow-up OCT to assess for malapposed/uncovered struts before stopping DAPT
DAPT= dual antiplatelet therapy; IMH= intramural hematoma; IVUS= intravascular ultrasound; PCI= percutaneous coronary intervention. [2]

References

  1. Adlam D, Cuculi F, Lim C, Banning A (2010). "Management of spontaneous coronary artery dissection in the primary percutaneous coronary intervention era". The Journal of Invasive Cardiology. 22 (11): 549–53. PMID 21041853.
  2. Saw J, Mancini GBJ, Humphries KH (2016). "Contemporary Review on Spontaneous Coronary Artery Dissection". J Am Coll Cardiol. 68 (3): 297–312. doi:10.1016/j.jacc.2016.05.034. PMID 27417009.