Spontaneous coronary artery dissection percutaneous coronary intervention

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 Case 1 Case 2 Case 3 Case 4 Case 5 Case 6 Case 7 Type 2A Case 1 Case 2 Case 3 Case 4 Case 5 Case 6 Type 2B Case 1 Case 2 Case 3 Case 4 Type 3 Case 1 Case 2 Case 3 Case 4 Case 5 Case 6

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Arzu Kalayci, M.D. [2] Nate Michalak, B.A.

Synonyms and keywords: SCAD

Overview

Conservative management should be the first choice if emergent revascularization is not necessary. However, optimal management is in question due to insufficient clinical experience. There are some treatment options including conservative management, emergency revascularization (PCI or CABG), fibrinolytic therapy, mechanical hemodynamic support, and even cardiac transplantation.The preference of the approach should be tailored to the patient’s clinical status.

Intervention

Conservative management should be first choice if emergent revascularization is not necessary.

• However, optimal management is in question due to insufficient clinical experience.
• There are some treatment options including conservative management, emergency revascularization (PCI or CABG), fibrinolytic therapy, mechanical hemodynamic support, and even cardiac transplantation.
• Preference of the approach should be tailored to patient’s clinical status.

Percutaneous Coronary Intervention

• Revascularization should be considered in case of acute myocardial infarction with symptoms or haemodynamic instability.
• However, PCI is technically quite difficult with a high risk of complications.
• Therefore, conservative management is recommended in patients with non-occlusive luminal obstruction, TIMI grade 3 flow, and a stable clinical condition.
• Performing PCI in SCAD is technically very difficult due to the arterial fragility.
• It can be quite challenging to keep the guidewire within the true lumen while crossing the lesion.
• Any instruments using in each stage such as wiring, angioplasty or stenting can enlarge the dissection and block side branches.
• In addition, these lesions are mostly require long stents resulting in higher rates of in stent restenosis.
• Furthermore, resorption of the intramural hematoma may lead to late stent malapposition and stent thrombosis.
• Therefore, stent implantation should only be performed in a strong clinical indication.
• It would be beneficial to perform procedure under the guidance of intracoronary imaging (IVUS, OCT).
• Although there is no evidence about the benefits of bioabsorbable stents, theoretically it seems to have advantages.

Challenges and Suggestions With SCAD PCI
Challenges during PCI of SCAD
Risk of iatrogenic catheter-induced dissection
Difficulty advancing coronary wire into the 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 the 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 a long stent in the middle
Consider bioabsorbable stents (temporary scaffold to avoid long-term 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.