Background:
Acute coronary syndromes occur in daily cardiologist’s practice. Atherosclerosis is doubtless the main etiology; however, it exists an alternative physiopathological mechanism: spontaneous coronary artery dissection (SCAD).
Atherosclerosis and SCAD do not share the same risk factors: typical SCAD epidemiology comprehends young women often in pregnancy. SCAD is caused by sudden disruption of the coronary artery wall, resulting in separation of the inner intimal lining from the outer vessel wall.
Case description:
F.C. a 37-years-old, female, entered to the Emergency Department (ED) referring typical chest discomfort radiating to jaw and upper limbs lasting two hours.
EKG presented ST segment elevation in V2-V4. Diagnosis of ACS-STEMI was performed. Urgent coronary angiography showed long dissection involving LDA.
At first due to clinical relief, the physicians suggested to a conservative treatment and a watchful waiting. Soon the patient experimented malignant arrhythmias and percutaneous revascularization was necessary.
True lumen engagement with guidewire was ensured by IVUS technique; Resolute Onyx 2.5 mmx34 mm was deployed in LDA mid tract, protecting the side brunch with further guidewire.
Because of retrograde squeezing of intramural hematoma, a further Resolute Onyx 3 mmx8 mm was released proximally overlapped the first stent. Good result TIMI 3.
After six months, the patient was asymptomatic and Coro CT confirmed the stents patency and absents of further dissections.
Discussion:
Randomized control trial about best treatment option in patient with SCAD are unavailable. Conservative therapy is often the first line, especially in dissections involving mid-distal tracts of main branch. The reason of this stands in a high percentage of spontaneous healing of dissections within 3-6 months,
From data available in medical literature, PCI performed in atherosclerosis coronaropathy has better outcomes than PCI performed in SCAD. The latter is associated with a larger incidence in periprocedural complications. False lumen engagement with guidewire and intramural hematoma ‘squeezing’ after stent dilatation are the typical procedure complications.
Conclusions:
Because of exiguous numbers, SCAD is a topic of large gap in evidence. Nowadays, lots of our knowledge about SCAD results from case reports or small meta-analysis. Indeed, the present case report offers it contribute to increase the state of art on this theme.
