How to Approach a Spontaneous Coronary Artery Dissection: An Up-To-Date

Abstract

AbstarctSpontaneous coronary artery dissection (SCAD) is a separation of the coronary wall layers, not related to trauma, medical procedures or atherosclerosis. The dissection causes the blood entry in the vascular wall with the consequent formation of a false lumen and intramural hematoma (IMH). Two pathogenetic mechanisms have been proposed to explain SCAD: a "primary" rupture of coronary endothelium or the rupture of the "vasa vasorum". Clinical presentation and severity of manifestations are variable, ranging from complete absence of symptoms to acute coronary syndrome (ACS), cardiogenic shock, cardiac arrest or sudden cardiac death. Despite coronary angiography is the first-line examination, by supplying two-dimensional images of the lumen, it does not always allow an incontrovertible diagnosis of SCAD. New intravascular imaging techniques, such as optical coherence tomography (OCT) and intravascular ultrasound (IVUS), have been recently introduced and may be extremely helpful in assessing the coronary wall integrity, thus improving coronary angiography diagnostic accuracy.Because of the lack of large randomized trials comparing different strategies, the optimal treatment of SCAD is still controversial. The first-line approach is conservative and based on medical therapy. Nevertheless, in particular situations an invasive approach is necessary. In the last years, several new strategies have improved the way to perform percutaneous coronary interventions (PCI), such as new generation drug eluting stents (DES), bio-resorbable scaffolds (BRS), sirolimus self-expandable stent (SES), drug eluting balloons (DEB), and cutting balloon. Cardiac artery bypass graft (CABG) is an even more invasive method to restore coronary flow and should be considered in urgent/emergent settings when PCI is not feasible or has failed.Cause the therapeutic approach of SCAD can be substantially different from that of atherosclerotic coronary artery disease, an accurate diagnosis is crucial to set up the best treatment strategy.

Perivascular Epicardial Fat Stranding at Coronary CT Angiography: A Marker of Acute Plaque Rupture and Spontaneous Coronary Artery Dissection

“…SCAD results from a nontraumatic, non-iatrogenic tear in the intimal layer of an artery leading to the intrusion of blood within the layers of an arterial wall or rupture of vasa vasorum (20). At coronary CT angiography, SCAD may demonstrate intramural hematoma, dissection flap, and coronary stenosis (21). Involvement of the media and adventitial extension have been described in arterial dissections (22,23).…”

Invasive and conservative treatment of spontaneous coronary artery dissection: a meta-analysis

“…По данным серии исследований клиники Ванкувера (Канада) [27], более чем в половине случаев наблюдалось перипроцедуральное увеличение зоны расслоения артерии, в 6 % случаях -тромбоз стента, в 12 % случаев ЧКВ завершилась экстренной операцией коронарного шунтирования. Причинами для недостаточной эффективности ЧКВ у пациентов с СДКА можно считать извитость, расслоение дистальных отделов коронарных артерий, возможность ятрогенного катетер-индуцированного повреждения сосудов во время интракоронарного маневрирования, введение проводника в зону ложного просвета вместо истинного, трудности выбора диаметра стента, особенно при СДКА 2-го и 3-го типов [45,51]. Обсуждая результаты анализа частоты реваскуляризации между группами, следует отметить и определенные этнические различия включенных в настоящий метаанализ исследований.…”

Coronary angioplasty in spontaneous coronary artery dissection—Strategy and outcomes

“…OCT owing to its higher spatial resolution is able to delineate the intimal characteristics of the dissection flap albeit at the cost of lower tissue penetration which prevents it from identifying the transverse extent of the intra mural hematoma. IVUS despite its lower spatial resolution has a better tissue penetration and is prefered over OCT because there is a risk of propagating the dissection by positive pressure perfusion during OCT 12 . Stable patients with SCAD are by default offered conservative management owing to the complex nature of the disease.…”