Spontaneous coronary artery dissection classification

Jump to: navigation, search

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).

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]

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
  • Diffuse (typically >20–30 mm)
  • Smooth narrowing varying in severity (ranging from 40 to 100% stenosis)
  • No response to intracoronary nitroglycerin
  • 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
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
  • Mimics atherosclerosis with focal or tubular stenosis
  • Lack of atherosclerotic changes in other coronary arteries
  • Long lesions (11–20 mm)
  • Hazy stenosis
  • Linear stenosis
  • Note: requires OCT or IVUS to prove the presence of intramural hematoma or double-lumen
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 arterial wall with multiple radiolucent lumens, with or without the presence of dye hang-up or slow contrast clearing from the lumen.

28-2-type-1-14RAO35CRA.gif 28-2 type 1 14RAO35CRA.jpg

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 an 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.

1-1-type-2A-RAD-25LAO20CRA.gif 1-1 type 2A RAD 25LAO20CRA.jpg

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.

24-1-type-2B-LAD-41RAO19CRA-TFG0.gif 24-1 type 2B LAD 41RAO19CRA TFG0.jpg

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

11-1 type 2B&3 1 LAO35CRA.gif 11-1 type 2B&3 1 LAO35CRA.jpg

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

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

Classification

There is no established system for the classification of [disease name].

OR

[Disease name] may be classified according to [classification method] into [number] subtypes/groups:

  • [Group1]
  • [Group2]
  • [Group3]
  • [Group4]

OR

[Disease name] may be classified into [large number > 6] subtypes based on:

  • [Classification method 1]
  • [Classification method 2]
  • [Classification method 3]

[Disease name] may be classified into several subtypes based on:

  • [Classification method 1]
  • [Classification method 2]
  • [Classification method 3]

OR

Based on the duration of symptoms, [disease name] may be classified as either acute or chronic.

OR

If the staging system involves specific and characteristic findings and features:

According to the [staging system + reference], there are [number] stages of [malignancy name] based on the [finding1], [finding2], and [finding3]. Each stage is assigned a [letter/number1] and a [letter/number2] that designate the [feature1] and [feature2].

OR

The staging of [malignancy name] is based on the [staging system].

OR

There is no established system for the staging of [malignancy name].

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.

Linked-in.jpg