Spontaneous coronary artery dissection classification: Difference between revisions

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__NOTOC__
__NOTOC__
{{Spontaneous coronary artery dissection}}
{{Spontaneous coronary artery dissection}}
{{CMG}}; {{AE}} {{NRM}}
{{CMG}}; {{AE}} {{NRM}}; {{AKK}}


{{SK}} SCAD
{{SK}} SCAD
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==Overview==
==Overview==


Spontaneous coronary artery dissection can be classified based on angiographic appearance into type 1 (evident arterial wall stain with multiple radiolucent lumens), type 2 (diffuse smooth stenosis of varying severity), and type 3 lesions (focal or tubular stenosis mimicking atherosclerosis).
[[Spontaneous coronary artery dissection]] can be classified based on [[angiographic]] appearance into type 1 (evident [[arterial]] wall stain with multiple [[radiolucent ]][[lumens]]), type 2 (diffuse [[smooth]] [[stenosis]] of varying severity), and type 3 [[lesions]] ([[focal]] or [[tubular]] [[stenosis]] mimicking [[atherosclerosis]]). Type 4 [[SCAD]] [[lesion]] is characterized by [[dissection]] leading to an abrupt total [[occlusion]], usually of a distal [[coronary]] segment.  The [[total occlusion]] occurs as a result of diminished true [[lumen]] due to external compression by [[intraluminal]] [[hematoma]] rather than [[embolism]]. The intermediate type 1/2 [[SCAD]] [[lesion]] is characterized by the appearance of type 1 in conjunction with type 2 [[lesion]].
 


==Classification==
==Classification==


The National Heart, Lung, and Blood Institute (NHLBI) classification scheme for [[coronary dissection]] was devised in the pre-stent era for classifying the dissection following balloon angioplasty (i.e., iatrogenic dissection).  In light of the distinctive angiographic features of spontaneous coronary artery dissection (SCAD), Saw et al. proposed a classification system to better characterize the lesions:<ref name="pmid24227590">{{cite journal| author=Saw J| title=Coronary angiogram classification of spontaneous coronary artery dissection. | journal=Catheter Cardiovasc Interv | year= 2014 | volume= 84 | issue= 7 | pages= 1115-22 | pmid=24227590 | doi=10.1002/ccd.25293 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24227590  }} </ref><ref name="pmid26198289">{{cite journal| author=Saw J, Mancini GB, Humphries K, Fung A, Boone R, Starovoytov A et al.| title=Angiographic appearance of spontaneous coronary artery dissection with intramural hematoma proven on intracoronary imaging. | journal=Catheter Cardiovasc Interv | year= 2016 | volume= 87 | issue= 2 | pages= E54-61 | pmid=26198289 | doi=10.1002/ccd.26022 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26198289  }} </ref>
The National Heart, Lung, and Blood Institute (NHLBI) classification scheme for [[coronary dissection]] was devised in the pre-stent era for classifying the [[dissection]] following balloon [[angioplasty]] (i.e., [[iatrogenic dissection]]).  In light of the distinctive [[angiographic]] features of [[spontaneous coronary artery dissection]] ([[SCAD]]), Saw et al. proposed a classification system to better characterize the [[lesions]]:<ref name="pmid24227590">{{cite journal| author=Saw J| title=Coronary angiogram classification of spontaneous coronary artery dissection. | journal=Catheter Cardiovasc Interv | year= 2014 | volume= 84 | issue= 7 | pages= 1115-22 | pmid=24227590 | doi=10.1002/ccd.25293 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24227590  }} </ref><ref name="pmid26198289">{{cite journal| author=Saw J, Mancini GB, Humphries K, Fung A, Boone R, Starovoytov A et al.| title=Angiographic appearance of spontaneous coronary artery dissection with intramural hematoma proven on intracoronary imaging. | journal=Catheter Cardiovasc Interv | year= 2016 | volume= 87 | issue= 2 | pages= E54-61 | pmid=26198289 | doi=10.1002/ccd.26022 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26198289  }} </ref><ref name="Al-HussainiAdlam2017">{{cite journal|last1=Al-Hussaini|first1=Abtehale|last2=Adlam|first2=David|title=Spontaneous coronary artery dissection|journal=Heart|volume=103|issue=13|year=2017|pages=1043–1051|issn=1355-6037|doi=10.1136/heartjnl-2016-310320}}</ref><ref name="AdlamAlfonso2018">{{cite journal|last1=Adlam|first1=David|last2=Alfonso|first2=Fernando|last3=Maas|first3=Angela|last4=Vrints|first4=Christiaan|last5=al-Hussaini|first5=Abtehale|last6=Bueno|first6=Hector|last7=Capranzano|first7=Piera|last8=Gevaert|first8=Sofie|last9=Hoole|first9=Stephen P|last10=Johnson|first10=Tom|last11=Lettieri|first11=Corrado|last12=Maeder|first12=Micha T|last13=Motreff|first13=Pascal|last14=Ong|first14=Peter|last15=Persu|first15=Alexandre|last16=Rickli|first16=Hans|last17=Schiele|first17=Francois|last18=Sheppard|first18=Mary N|last19=Swahn|first19=Eva|title=European Society of Cardiology, acute cardiovascular care association, SCAD study group: a position paper on spontaneous coronary artery dissection|journal=European Heart Journal|year=2018|issn=0195-668X|doi=10.1093/eurheartj/ehy080}}</ref><ref name="KimLongo2020">{{cite journal|last1=Kim|first1=Esther S.H.|last2=Longo|first2=Dan L.|title=Spontaneous Coronary-Artery Dissection|journal=New England Journal of Medicine|volume=383|issue=24|year=2020|pages=2358–2370|issn=0028-4793|doi=10.1056/NEJMra2001524}}</ref>
 


{| class="wikitable" style="font-size: 85%;"
{| class="wikitable" style="font-size: 85%;"
Line 19: Line 21:
| style="background: #DCDCDC; padding: 5px; text-align: center;" | '''Type 1'''
| style="background: #DCDCDC; padding: 5px; text-align: center;" | '''Type 1'''
| style="background: #F5F5F5; padding: 5px;" colspan="2;"|
| style="background: #F5F5F5; padding: 5px;" colspan="2;"|
*Pathognomonic multiple radiolucent lumen
* Pathognomonic multiple [[radiolucent]] lumen
*Contrast dye staining of arterial wall  
* Contrast dye staining of [[arterial]] wall  
*Presence or absence of dye hang-up or slow contrast clearing from the lumen
* Presence or absence of [[dye]] hang-up or slow contrast clearing from the [[lumen]]
|-
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" rowspan="3;" | '''Type 2'''
| style="background: #DCDCDC; padding: 5px; text-align: center;" rowspan="3;" | '''Type 2'''
| style="background: #F5F5F5; padding: 5px;" colspan="2;"|
| style="background: #F5F5F5; padding: 5px;" colspan="2;"|
*Diffuse (typically >20–30 mm)
* The most common form (60-75% of the [[patients]])
*Smooth narrowing varying in severity (ranging from 40 to 100% stenosis)
* Diffuse (typically >20–30 mm)
*No response to intracoronary nitroglycerin
* Smooth narrowing varying in severity (ranging from 40 to 100% stenosis)
*No atherosclerotic lesions in other coronary arteries
* Appears as a sudden change in the caliber of the [[artery]]
*Repeat coronary angiogram showing spontaneous resolution of the dissected segment or previous angiogram showing normal artery
* No response to [[intracoronary]] [[nitroglycerin]]
*Intracoronary imaging with OCT or IVUS proving the presence of intramural hematoma and double-lumen
* No [[atherosclerotic]] lesions in other [[coronary arteries]]
* Repeat [[coronary angiogram]] showing spontaneous resolution of the [[dissected]] segment or previous [[angiogram]] showing normal [[artery]]
* Intracoronary imaging with [[OCT]] or [[IVUS]] proving the presence of [[intramural]] [[hematoma]] and double-[[lumen]]
|-
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''2A variant'''
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''2A variant'''
| style="background: #F5F5F5; padding: 5px;" |Normal arterial caliber proximal and distal to dissection
| style="background: #F5F5F5; padding: 5px;" |Normal [[arterial]] caliber proximal and distal to [[dissection]]
|-
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''2B variant'''
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''2B variant'''
| style="background: #F5F5F5; padding: 5px;" |Dissection extends to the distal tip of the artery without discernible normal segment distally
| style="background: #F5F5F5; padding: 5px;" |Dissection extends to the distal tip of the [[artery]] without discernible normal segment distally
|-
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" | '''Type 3'''
| style="background: #DCDCDC; padding: 5px; text-align: center;" | '''Type 3'''
| style="background: #F5F5F5; padding: 5px;" colspan="2;"|
| style="background: #F5F5F5; padding: 5px;" colspan="2;"|
*Mimics atherosclerosis with focal or tubular stenosis
* Mimics [[atherosclerosis]] with focal or [[tubular stenosis]]
*Lack of atherosclerotic changes in other coronary arteries
* Lack of [[atherosclerotic]] changes in other [[coronary arteries]]
*Long lesions (11–20 mm)
* Long lesions (11–20 mm)
*Hazy stenosis
* Hazy [[stenosis]]
*Linear stenosis
* Linear [[stenosis]]
*Note: requires OCT or IVUS to prove the presence of intramural hematoma or double-lumen
* Note: requires [[OCT]] or [[IVUS]] to prove the presence of intramural [[hematoma]] or double-lumen
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" | '''Type 4'''
| style="background: #F5F5F5; padding: 5px;" colspan="2;"|
* Abrupt total vessel occlusion
* Usually involves a distal segment
* Sources of [[coronary embolism]] have been excluded
* Subsequent evidence of complete vessel healing in keeping with the natural history of [[SCAD]]
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" | '''Intermediate Type 1/2'''
| style="background: #F5F5F5; padding: 5px;" colspan="2;"|
* Diffuse smooth narrowing (type 2 appearance)
* [[Arterial]] wall stain with multiple radiolucent lumens in keeping with a localized fenestration between true and [[false lumen]] (type 1 appearance)
|-
|}
|}


==Spontaneous Coronary Artery Dissection Type 1==
==Spontaneous Coronary Artery Dissection Type 1==


Type 1 SCAD lesion is characterized by the pathognomonic appearance of contrast dye staining of arterial wall with multiple radiolucent lumens, with or without the presence of dye hang-up or slow contrast clearing from the lumen.
Type 1 [[SCAD]] [[lesion]] is characterized by the pathognomonic appearance of contrast dye staining of the [[arterial]] wall with multiple [[radiolucent]] [[lumens]], with or without the presence of [[dye]] hang-up or [[slow]] [[contrast]] clearing from the [[lumen]].


[[File:28-2-type-1-14RAO35CRA.gif|500px|]]
[[File:28-2-type-1-14RAO35CRA.gif|500px|]]
[[File:28-2 type 1 14RAO35CRA.jpg|500px|]]
[[File:28-2 type 1 14RAO35CRA.jpg|500px|]]


<span style="font-size:85%">Projection angle: 14 RAO, 35 CRA. Type 1 SCAD is seen in OM2.</span>
<span style="font-size:85%">Projection angle: 14 RAO, 35 CRA. Type 1 [[SCAD]] is seen in [[OM]]2.</span>


==Spontaneous Coronary Artery Dissection Type 2==
==[[Spontaneous Coronary Artery Dissection]] Type 2==


Type 2 SCAD lesion is characterized diffuse (typically >20–30 mm) and usually smooth narrowing that can vary in severity from an inconspicuous mild stenosis to complete occlusion, plus:
Type 2 [[SCAD]] [[lesion]] is characterized by diffuse (typically >20–30 mm) and usually smooth narrowing that can vary in severity from inconspicuous mild [[stenosis]] to complete [[occlusion]], plus:
: a. no response to intracoronary [[nitroglycerin]] and no atherosclerotic lesions in other coronary arteries
: a. no response to intracoronary [[nitroglycerin]] and no [[atherosclerotic]] [[lesions]] in other [[coronary arteries]]
: '''OR'''
: '''OR'''
: b. repeat coronary angiogram showing angiographic resolution of the dissected segment or previous angiogram showing normal artery
: b. repeat [[coronary]] [[angiogram]] showing [[angiographic]] resolution of the [[dissected segment]] or previous [[angiogram]] showing [[normal]] [[artery]]
: '''OR'''
: '''OR'''
: c. intracoronary imaging with [[optical coherence tomography]] or [[intravascular ultrasound]] proving the presence of intramural [[hematoma]] (IMH) and double-lumen
: c. intracoronary [[imaging]] with [[optical coherence tomography]] or [[intravascular ultrasound]] proving the presence of intramural [[hematoma]] ([[IMH]]) and double-[[lumen]]


Type 2 SCAD lesion commonly involves the mid to distal segments of coronary arteries, and can be so extensive that it affects the distal tip.  Accordingly, type 2 lesions can be further divided into two variants (type 2 variant A and variant B).
Type 2 [[SCAD]] [[lesion]] commonly involves the mid to distal segments of [[coronary arteries]] and can be so extensive that it affects the distal tip.  Accordingly, type 2 [[lesions]] can be further divided into two variants (type 2 variant A and variant B).


===Type 2 Variant A===
===Type 2 Variant A===


In type 2 variant A lesion, the coronary segments proximal and distal to dissection are normal.
In type 2 variant A [[lesion]], the coronary segments proximal and distal to [[dissection]] are normal.


[[File:1-1-type-2A-RAD-25LAO20CRA.gif|500px|]]
[[File:1-1-type-2A-RAD-25LAO20CRA.gif|500px|]]
[[File:1-1 type 2A RAD 25LAO20CRA.jpg|500px|]]
[[File:1-1 type 2A RAD 25LAO20CRA.jpg|500px|]]


<span style="font-size:85%">Projection angle: 25 LAO, 20 CRA. Type 2A SCAD is seen in R3, R4.</span>
<span style="font-size:85%">Projection angle: 25 [[LAO]], 20 CRA. Type 2A [[SCAD]] is seen in R3, R4.</span>


===Type 2 Variant B===
===Type 2 Variant B===


In type 2 variant B lesion, the dissection extends to the apical tip of the artery without discernible normal segment distally.
In type 2 variant B [[lesion]], the dissection extends to the [[apical]] tip of the [[artery]] without discernible normal segment distally.


[[File:24-1-type-2B-LAD-41RAO19CRA-TFG0.gif|500px|]]
[[File:24-1-type-2B-LAD-41RAO19CRA-TFG0.gif|500px|]]
[[File:24-1 type 2B LAD 41RAO19CRA TFG0.jpg|500px|]]
[[File:24-1 type 2B LAD 41RAO19CRA TFG0.jpg|500px|]]


<span style="font-size:85%">Projection angle: 41 RAO, 19 CRA. Type 2B SCAD is seen starting in L2 resulting in a total occlusion.</span>
<span style="font-size:85%">Projection angle: 41 [[RAO]], 19 CRA. Type 2B [[SCAD]] is seen starting in L2 resulting in a total [[occlusion]].</span>


==Spontaneous Coronary Artery Dissection Type 3==
==Spontaneous Coronary Artery Dissection Type 3==


Type 3 SCAD lesion is characterized by focal or tubular (typically <20 mm) stenosis that mimics [[atherosclerosis]], which requires intracoronary imaging (e.g. [[optical coherence tomography]] or [[intravascular ultrasound]]) to prove the presence of intramural hematoma or double-lumen.  Angiographic features that may be useful in differentiating type 3 SCAD lesion from [[atherosclerosis]] include:
Type 3 [[SCAD]] [[lesion]] is characterized by focal or [[tubular]] (typically <20 mm) [[stenosis]] that mimics [[atherosclerosis]], which requires [[intracoronary]] [[imaging]] (e.g. [[optical coherence tomography]] or [[intravascular ultrasound]]) to prove the presence of intramural [[hematoma]] or double-lumen.  [[Angiographic]] features that may be useful in differentiating type 3 [[SCAD]] [[lesion]] from [[atherosclerosis]] include:
: a. lack of [[atherosclerotic]] changes in other coronary arteries
: a. lack of [[atherosclerotic]] changes in other [[coronary arteries]]
: b. long lesions (11–20 mm)
: b. long [[lesions]] (11–20 mm)
: c. hazy stenosis
: c. hazy [[stenosis]]
: d. linear stenosis
: d. linear [[stenosis]]


[[File:11-1 type 2B&3 1 LAO35CRA.gif|500px|]]
[[File:11-1 type 2B&3 1 LAO35CRA.gif|500px|]]
[[File:11-1 type 2B&3 1 LAO35CRA.jpg|500px|]]
[[File:11-1 type 2B&3 1 LAO35CRA.jpg|500px|]]


<span style="font-size:85%">Projection angle: 1 LAO, 35 CRA. Type 3 SCAD is seen in D1.</span>
<span style="font-size:85%">[[Projection angle]]: 1 [[LAO]], 35 CRA. Type 3 SCAD is seen in D1.</span>
 
==Algorithm for Angiographic Diagnosis of Non-Atherosclerotic Spontaneous Coronary Artery Dissection==
 
A stepwise algorithm for diagnosing non-atherosclerotic SCAD has been proposed by Saw et al.<ref name="pmid24227590">{{cite journal| author=Saw J| title=Coronary angiogram classification of spontaneous coronary artery dissection. | journal=Catheter Cardiovasc Interv | year= 2014 | volume= 84 | issue= 7 | pages= 1115-22 | pmid=24227590 | doi=10.1002/ccd.25293 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24227590  }}</ref>  Clinicians should maintain a high index of suspicion for SCAD and consider early coronary angiography to ensure timely diagnosis and management.  If the pathognomonic appearance of arterial wall stain with multiple radiolucent lumens is evident, then the diagnosis of type 1 SCAD can be established without additional intracoronary imaging.  If type 1 SCAD appearance is not evident, angiographers should then assess for the presence of atherosclerotic changes in other coronary arteries, and consider intracoronary imaging if there is uncertainty as to non-atherosclerotic SCAD.  For diffuse (>20 mm) and smooth stenosis of varying severity suggestive of type 2 SCAD, intracoronary [[nitroglycerin]] may be administered to rule out [[coronary spasm]].  If the stenosis remains unchanged after [[nitroglycerin]] administration, then [[optical coherence tomography]] (OCT) or [[intravascular ultrasound]] (IVUS) should be pursued.  If there are concerns of compromising coronary flow with intracoronary imaging, then the stenosis could be reassessed in 4 to 6 weeks for hemodynamically stable patients, as SCAD typically resolves spontaneously.
 
<div style="font-size: 80%;" align="center">
 
<BR><span style="font-size: 1.5em; font-weight: bold;">Algorithm for the Angiographic Diagnosis and Confirmation of Spontaneous Coronary Artery Dissection</span><ref name="pmid24227590">{{cite journal| author=Saw J| title=Coronary angiogram classification of spontaneous coronary artery dissection. | journal=Catheter Cardiovasc Interv | year= 2014 | volume= 84 | issue= 7 | pages= 1115-22 | pmid=24227590 | doi=10.1002/ccd.25293 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24227590}}</ref><BR><BR>
 
{{Familytree/start}}
{{Familytree | | | | | A01 | | | | | | | | |
A01=<div style="text-align: left; font-weight: bold; padding: 5px;">
<div class="mw-customtoggle-x1" style="cursor: pointer;>
Presence of features that raise suspicion for SCAD?<BR><span style="color: #0645AD;">(click for details)</span>
</div>
<div class="mw-collapsible mw-collapsed" id="mw-customcollapsible-x1" style="font-size: 10px;">
----
❑&nbsp;&nbsp;[[Myocardial infarction]] in young women (age ≤50)
 
❑&nbsp;&nbsp;Absence of traditional [[Cardiovascular disease#Risk factors|cardiovascular risk factors]]
 
❑&nbsp;&nbsp;Little or no evidence of [[coronary atherosclerosis]]
 
❑&nbsp;&nbsp;[[Peripartum|Peripartum state]]
 
❑&nbsp;&nbsp;History of [[fibromuscular dysplasia]]
 
❑&nbsp;&nbsp;History of [[connective tissue disorder]] or [[systemic inflammation]]
 
&nbsp;&nbsp;&nbsp;&nbsp;❑&nbsp;&nbsp;[[Marfan's syndrome]]
 
&nbsp;&nbsp;&nbsp;&nbsp;❑&nbsp;&nbsp;[[Ehlers-Danlos syndrome|Type 4 Ehlers-Danlos syndrome]]
 
&nbsp;&nbsp;&nbsp;&nbsp;❑&nbsp;&nbsp;[[Loeys-Dietz syndrome]]
 
&nbsp;&nbsp;&nbsp;&nbsp;❑&nbsp;&nbsp;[[Cystic medial necrosis]]
 
&nbsp;&nbsp;&nbsp;&nbsp;❑&nbsp;&nbsp;[[Systemic lupus erythematosus]]
 
&nbsp;&nbsp;&nbsp;&nbsp;❑&nbsp;&nbsp;[[Crohn's disease]]
 
&nbsp;&nbsp;&nbsp;&nbsp;❑&nbsp;&nbsp;[[Ulcerative colitis]]
 
&nbsp;&nbsp;&nbsp;&nbsp;❑&nbsp;&nbsp;[[Polyarteritis nodosa]]
 
&nbsp;&nbsp;&nbsp;&nbsp;❑&nbsp;&nbsp;[[Sarcoidosis]]
 
&nbsp;&nbsp;&nbsp;&nbsp;❑&nbsp;&nbsp;[[Churg-Strauss syndrome]]
 
&nbsp;&nbsp;&nbsp;&nbsp;❑&nbsp;&nbsp;[[Wegener's granulomatosis]]
 
&nbsp;&nbsp;&nbsp;&nbsp;❑&nbsp;&nbsp;[[Rheumatoid arthritis]]
 
&nbsp;&nbsp;&nbsp;&nbsp;❑&nbsp;&nbsp;[[Giant cell arteritis]]
----
</div>
</div>}}
{{Familytree | | | | | |!| | | | | | | | | | }}
{{Familytree | | | | | B01 | | | | | | | | |
B01=<div style="text-align: left; font-weight: bold; padding: 5px;">
Perform early coronary angiography
</div>}}
{{Familytree | | | | | |!| | | | | | | | | | }}
{{Familytree | | | | | C01 | | | | | | | | |
C01=<div style="text-align: left; font-weight: bold; padding: 5px;">
<div class="mw-customtoggle-x2" style="cursor: pointer;>
Presence of type 1 SCAD lesion characteristics?<BR><span style="color: #0645AD;">(click for details)</span>
</div>
<div class="mw-collapsible mw-collapsed" id="mw-customcollapsible-x2" style="font-size: 10px;">
----
❑&nbsp;&nbsp;Contrast staining of arterial wall
 
❑&nbsp;&nbsp;Multiple radiolucent lumens
 
❑&nbsp;&nbsp;Contrast hang-up or slow clearing from the lumen
----
</div>
</div>}}
{{Familytree | |,|-|-|-|^|-|-|-|.| | | | | | }}
{{Familytree | D01 | | | | | | D02 | | | | |
D01=<div style="text-align: center; font-weight: bold; padding: 5px;">YES</div>|
D02=<div style="text-align: center; font-weight: bold; padding: 5px;">NO</div>
}}
{{Familytree | |!| | | | | | | |!| | | | | | }}
{{Familytree | E01 | | | | | | E02 | | | | |
E01=<div style="text-align: left; font-weight: bold; padding: 5px;">Type 1 SCAD most likely</div>|
E02=<div style="text-align: left; font-weight: bold; padding: 5px;">
<div class="mw-customtoggle-x3" style="cursor: pointer;>
Presence of type 2 SCAD lesion characteristics?<BR><span style="color: #0645AD;">(click for details)</span>
</div>
<div class="mw-collapsible mw-collapsed" id="mw-customcollapsible-x3" style="font-size: 10px;">
----
❑&nbsp;&nbsp;Diffuse lesion (typically >20–30 mm)
❑&nbsp;&nbsp;Smooth luminal narrowing with varying severity
 
❑&nbsp;&nbsp;Involvement of mid to distal segments
----
</div>
</div>
}}
{{Familytree | | | | | |,|-|-|-|^|-|-|-|.| | }}
{{Familytree | | | | | F01 | | | | | | F02 |
F01=<div style="text-align: center; font-weight: bold; padding: 5px;">YES</div>|
F02=<div style="text-align: center; font-weight: bold; padding: 5px;">NO</div>
}}
{{Familytree | | | | | |!| | | | | | | |!| | }}
{{Familytree | | | | | G01 | | | | | | G02 |
G01=<div style="text-align: left; font-weight: bold; padding: 5px;">Stenosis corrected by intracoronary nitroglycerin?</div>|
G02=<div style="text-align: left; font-weight: bold; padding: 5px;">
<div class="mw-customtoggle-x4" style="cursor: pointer;>
Look for type 3 SCAD lesion characteristics<BR><span style="color: #0645AD;">(click for details)</span>
</div>
<div class="mw-collapsible mw-collapsed" id="mw-customcollapsible-x4" style="font-size: 10px;">
----
❑&nbsp;&nbsp;Focal or tubular stenosis (typically <20 mm)
❑&nbsp;&nbsp;Mimics atherosclerosis
 
❑&nbsp;&nbsp;Additional features
 
&nbsp;&nbsp;&nbsp;&nbsp;❑&nbsp;&nbsp;No atherosclerosis in other arteries
 
&nbsp;&nbsp;&nbsp;&nbsp;❑&nbsp;&nbsp;Long lesions (11–20 mm)
 
&nbsp;&nbsp;&nbsp;&nbsp;❑&nbsp;&nbsp;Hazy stenosis
 
&nbsp;&nbsp;&nbsp;&nbsp;❑&nbsp;&nbsp;Linear stenosis
----
</div>
</div>
}}
{{Familytree | |,|-|-|-|^|-|-|-|.| | | |!| | }}
{{Familytree | H01 | | | | | | H02 | | H03 |
H01=<div style="text-align: center; font-weight: bold; padding: 5px;">YES</div>|
H02=<div style="text-align: center; font-weight: bold; padding: 5px;">NO</div>|
H03=<div style="text-align: left; font-weight: bold; padding: 5px;">
Type 3 SCAD most likely
 
❑&nbsp;&nbsp;Consider OCT or IVUS for definitive diagnosis


❑&nbsp;&nbsp;Reassess with angiography in 4 to 6 weeks
==[[Spontaneous Coronary Artery Dissection]] Type 4==
</div>
}}
{{Familytree | |!| | | | | | | |!| | | | | | }}
{{Familytree | I01 | | | | | | I02 | | | | |
I01=<div style="text-align: left; font-weight: bold; padding: 5px;">R/O coronary spasm or other conditions</div>|
I02=<div style="text-align: left; font-weight: bold; padding: 5px;">
Type 2 SCAD most likely


❑&nbsp;&nbsp;Consider OCT or IVUS for definitive diagnosis
Type 4 [[SCAD]] [[lesion]] is characterized by [[dissection]] leading to an abrupt total [[occlusion]], usually of a distal [[coronary]] segment.  The [[total occlusion]] occurs as a result of diminished true [[lumen]] due to external compression by [[intraluminal]] [[hematoma]] rather than [[embolism]].  In keeping with the natural history of [[SCAD]], spontaneous healing may be evident on subsequent [[angiography]].


❑&nbsp;&nbsp;Reassess with angiography in 4 to 6 weeks
==[[Spontaneous Coronary Artery Dissection]] Intermediate Type 1/2==
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The intermediate type 1/2 [[SCAD]] [[lesion]] is characterized by the appearance of type 1 in conjunction with type 2 [[lesion]].  Diffuse, smooth narrowing of the [[vessel]] (suggestive of type 2 [[lesion]]) adjacent to multiple [[radiolucent]] [[lumens]] with [[arterial]] [[wall]] staining (suggestive of a type 1 [[lesion]]) is observed.
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==References==
==References==
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[[Category:Angiographic Definitions]]
[[Category:Angiographic Definitions]]
[[Category:Disease]]
[[Category:Disease]]
[[Category:Up To Date]]

Latest revision as of 12:47, 20 April 2021

Spontaneous Coronary Artery Dissection Microchapters

Home

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.; Arzu Kalayci, M.D. [2]

Synonyms and keywords: SCAD

Overview

Spontaneous coronary artery dissection can be classified based on angiographic appearance into type 1 (evident arterial wall stain with multiple radiolucent lumens), type 2 (diffuse smooth stenosis of varying severity), and type 3 lesions (focal or tubular stenosis mimicking atherosclerosis). Type 4 SCAD lesion is characterized by dissection leading to an abrupt total occlusion, usually of a distal coronary segment. The total occlusion occurs as a result of diminished true lumen due to external compression by intraluminal hematoma rather than embolism. The intermediate type 1/2 SCAD lesion is characterized by the appearance of type 1 in conjunction with type 2 lesion.


Classification

The National Heart, Lung, and Blood Institute (NHLBI) classification scheme for coronary dissection was devised in the pre-stent era for classifying the dissection following balloon angioplasty (i.e., iatrogenic dissection). In light of the distinctive angiographic features of spontaneous coronary artery dissection (SCAD), Saw et al. proposed a classification system to better characterize the lesions:[1][2][3][4][5]


Type Feature
Type 1
  • Pathognomonic multiple radiolucent lumen
  • Contrast dye staining of arterial wall
  • Presence or absence of dye hang-up or slow contrast clearing from the lumen
Type 2
2A variant Normal arterial caliber proximal and distal to dissection
2B variant Dissection extends to the distal tip of the artery without discernible normal segment distally
Type 3
Type 4
  • Abrupt total vessel occlusion
  • Usually involves a distal segment
  • Sources of coronary embolism have been excluded
  • Subsequent evidence of complete vessel healing in keeping with the natural history of SCAD
Intermediate Type 1/2
  • Diffuse smooth narrowing (type 2 appearance)
  • Arterial wall stain with multiple radiolucent lumens in keeping with a localized fenestration between true and false lumen (type 1 appearance)

Spontaneous Coronary Artery Dissection Type 1

Type 1 SCAD lesion is characterized by the pathognomonic appearance of contrast dye staining of the arterial wall with multiple radiolucent lumens, with or without the presence of dye hang-up or slow contrast clearing from the lumen.

Projection angle: 14 RAO, 35 CRA. Type 1 SCAD is seen in OM2.

Spontaneous Coronary Artery Dissection Type 2

Type 2 SCAD lesion is characterized by diffuse (typically >20–30 mm) and usually smooth narrowing that can vary in severity from inconspicuous mild stenosis to complete occlusion, plus:

a. no response to intracoronary nitroglycerin and no atherosclerotic lesions in other coronary arteries
OR
b. repeat coronary angiogram showing angiographic resolution of the dissected segment or previous angiogram showing normal artery
OR
c. intracoronary imaging with optical coherence tomography or intravascular ultrasound proving the presence of intramural hematoma (IMH) and double-lumen

Type 2 SCAD lesion commonly involves the mid to distal segments of coronary arteries and can be so extensive that it affects the distal tip. Accordingly, type 2 lesions can be further divided into two variants (type 2 variant A and variant B).

Type 2 Variant A

In type 2 variant A lesion, the coronary segments proximal and distal to dissection are normal.

Projection angle: 25 LAO, 20 CRA. Type 2A SCAD is seen in R3, R4.

Type 2 Variant B

In type 2 variant B lesion, the dissection extends to the apical tip of the artery without discernible normal segment distally.

Projection angle: 41 RAO, 19 CRA. Type 2B SCAD is seen starting in L2 resulting in a total occlusion.

Spontaneous Coronary Artery Dissection Type 3

Type 3 SCAD lesion is characterized by focal or tubular (typically <20 mm) stenosis that mimics atherosclerosis, which requires intracoronary imaging (e.g. optical coherence tomography or intravascular ultrasound) to prove the presence of intramural hematoma or double-lumen. Angiographic features that may be useful in differentiating type 3 SCAD lesion from atherosclerosis include:

a. lack of atherosclerotic changes in other coronary arteries
b. long lesions (11–20 mm)
c. hazy stenosis
d. linear stenosis

Projection angle: 1 LAO, 35 CRA. Type 3 SCAD is seen in D1.

Spontaneous Coronary Artery Dissection Type 4

Type 4 SCAD lesion is characterized by dissection leading to an abrupt total occlusion, usually of a distal coronary segment. The total occlusion occurs as a result of diminished true lumen due to external compression by intraluminal hematoma rather than embolism. In keeping with the natural history of SCAD, spontaneous healing may be evident on subsequent angiography.

Spontaneous Coronary Artery Dissection Intermediate Type 1/2

The intermediate type 1/2 SCAD lesion is characterized by the appearance of type 1 in conjunction with type 2 lesion. Diffuse, smooth narrowing of the vessel (suggestive of type 2 lesion) adjacent to multiple radiolucent lumens with arterial wall staining (suggestive of a type 1 lesion) is observed.

References

  1. Saw J (2014). "Coronary angiogram classification of spontaneous coronary artery dissection". Catheter Cardiovasc Interv. 84 (7): 1115–22. doi:10.1002/ccd.25293. PMID 24227590.
  2. Saw J, Mancini GB, Humphries K, Fung A, Boone R, Starovoytov A; et al. (2016). "Angiographic appearance of spontaneous coronary artery dissection with intramural hematoma proven on intracoronary imaging". Catheter Cardiovasc Interv. 87 (2): E54–61. doi:10.1002/ccd.26022. PMID 26198289.
  3. Al-Hussaini, Abtehale; Adlam, David (2017). "Spontaneous coronary artery dissection". Heart. 103 (13): 1043–1051. doi:10.1136/heartjnl-2016-310320. ISSN 1355-6037.
  4. Adlam, David; Alfonso, Fernando; Maas, Angela; Vrints, Christiaan; al-Hussaini, Abtehale; Bueno, Hector; Capranzano, Piera; Gevaert, Sofie; Hoole, Stephen P; Johnson, Tom; Lettieri, Corrado; Maeder, Micha T; Motreff, Pascal; Ong, Peter; Persu, Alexandre; Rickli, Hans; Schiele, Francois; Sheppard, Mary N; Swahn, Eva (2018). "European Society of Cardiology, acute cardiovascular care association, SCAD study group: a position paper on spontaneous coronary artery dissection". European Heart Journal. doi:10.1093/eurheartj/ehy080. ISSN 0195-668X.
  5. Kim, Esther S.H.; Longo, Dan L. (2020). "Spontaneous Coronary-Artery Dissection". New England Journal of Medicine. 383 (24): 2358–2370. doi:10.1056/NEJMra2001524. ISSN 0028-4793.