Recurrent Spontaneous Coronary Artery Dissection Managed With Intravascular Ultrasound Guided Percutaneous Coronary Intervention
Presenter
Quinn Mallery, MD MPH, Loyola University Medical Center, Elmhurst, IL
Quinn Mallery, MD MPH, Loyola University Medical Center, Elmhurst, IL, Frances Greathouse, MD, Loyola University Medical Center, Wheaton, IL, Jacob Clarke, MD, Loyola University Medical Center, Oak Park, IL, Ali Hasnie, MD MPH, Loyola University Medical Center, Chicago, IL and Amir Darki, M.D. MSc, FSCAI, Loyola University Medical Center, Hinsdale, IL
Title:
Recurrent Spontaneous Coronary Artery Dissection Managed With Intravascular Ultrasound Guided Percutaneous Coronary Intervention.
Introduction:
Spontaneous coronary artery dissection (SCAD) accounts for up to 35% of myocardial infarctions in women under 50. Initial management depends on clinical stability, given the risk of dissection propagation with percutaneous coronary intervention (PCI). Recurrence occurs in 15-22% of patients within 2-3 years, warranting evaluation for revascularization in those with persistent angina. This report details a case of recurrent symptomatic SCAD managed through intravascular ultrasound (IVUS)-guided PCI.
Clinical Case:
A 46-year-old female with history of recurrent SCAD, non-ST-elevation myocardial infarction (NSTEMI) status post drug-eluting stent (DES) to the mid left anterior descending artery (LAD) and staged DES to the distal circumflex, ST-elevation MI (STEMI) status post balloon angioplasty to a proximal LAD dissection, STEMI due to right coronary artery (RCA) dissection managed medically, carotid ophthalmic artery aneurysm, and fibromuscular dysplasia presented to clinic with functionally limiting angina symptoms despite medical management with a beta blocker, anti-hypertensives, long-acting nitrates, dual-antiplatelet therapy, and cardiac rehabilitation. A coronary computed tomography angiogram (CTA), obtained one year after STEMI, showed persistent 70-99% stenosis in the proximal RCA. Invasive coronary angiography revealed a type 1 dissection of the proximal RCA. After shared decision between the patient, interventional cardiology, and cardiac surgery, the patient returned to the catheterization lab for IVUS-guided PCI. A Prowater Flex wire was initially used and was escalated to an Asahi Sion Blue to wire distally into the RCA before being exchanged again for a Prowater Flex wire. Intravascular ultrasound confirmed the wire position as being luminal. Three DES were placed ostially to the mid RCA. To prevent propagation of the dissection, the stents were purposely undersized and a conservative strategy for post dilatation was employed resulting in some segments of the stent not fully expanded on IVUS. There was no residual stenosis or distal edge dissection seen. Her post-operative course was complicated by pericarditis, effectively treated with ibuprofen and colchicine dual therapy. Afterwards, she noted improved exercise tolerance, nitrate use, and dyspnea. Unfortunately, 10 months post-procedure, she developed recurrent angina. Coronary CTA revealed a new focal lesion distal to the stent in the mid RCA as well as probable dissection in the LAD system for which she has opted for continued medical management.
Discussion:
SCAD recurrence, whether through extension of the intramural hematoma or de novo dissection, is prevalent. Various cardiac imaging techniques aid in evaluating recurrent dissection and optimizing management. Coronary CTA, a noninvasive method with high sensitivity and specificity for atherosclerosis, can miss SCAD hematoma due to the absence of typical markers such as calcification. Thus, coronary CTA may prove most helpful in assessing for recurrence in known SCAD cases. Intravascular techniques like IVUS and optical coherence tomography can help diagnose angiographically ambiguous SCAD. They also help optimize stent placement, reducing the risk of malposition secondary to hematoma resorption. In our case, these techniques facilitated the treatment of recurrent SCAD through PCI. Her recurrence of multivessel dissections stresses the importance of continued research into optimal SCAD management and prevention.