Prevalence of Cervical Artery Abnormalities on CTA in Patients with Spontaneous Coronary Artery Dissection: Fibromuscular Dysplasia, Dissection, Aneurysm, and Tortuosity

Abstract

BACKGROUND AND PURPOSE:Little is known about associations between spontaneous coronary artery dissection and cervical artery abnormalities. This study sought to assess the prevalence of cervical artery abnormalities among patients with spontaneous coronary artery dissection. MATERIALS AND METHODS:A retrospective analysis was completed of patients who underwent CTA neck imaging as part of arterial assessment following the diagnosis of spontaneous coronary artery dissection. The internal carotid and vertebral arteries were evaluated for the presence of fibromuscular dysplasia, dissection and/or pseudoaneurysm, ectasia and/or aneurysmal dilation, atherosclerosis, and webs. Carotid tortuosity was categorized into kinks, loops, coils, and retrojugular and/or retropharyngeal carotid courses; vertebral tortuosity was classified by subjective analysis of severity.RESULTS: Two hundred fourteen patients were included in the final cohort, of whom 205 (95.8%) were women; the average age was 54.4 years. Fibromuscular dysplasia was the most frequently observed abnormality (83 patients; 38.8%), followed by dissections and/or pseudoaneurysms (n ¼ 28; 13.1%), ectasia and/or aneurysmal dilation (n ¼ 22; 10.3%), and carotid webs (n ¼ 10; 4.7%). At least 1 type of carotid tortuosity was present in 99 patients (46.3%). The majority (n ¼ 185; 86.4%) of patients had no carotid atherosclerosis; and 26 (12.2%) had mild; 3 (1.4%), moderate; and 0, severe carotid atherosclerosis. CONCLUSIONS:The most common abnormality in the cervical artery vasculature of patients with spontaneous coronary artery dissection is fibromuscular dysplasia. Cervical dissections were higher than previously reported but were not observed in most patients. ABBREVIATIONS: ACS ¼ acute coronary syndrome; CTD ¼ connective tissue disorder; FMD ¼ fibromuscular dysplasia; SCAD ¼ spontaneous coronary artery dissection S pontaneous coronary artery dissection (SCAD) is an increasingly recognized cause of acute coronary syndrome (ACS), predominantly affecting otherwise healthy young and middleaged women. 1,2 By definition, it refers to dissection of the coronary artery wall in the absence of trauma, atherosclerosis, or iatrogenic causes. 3 The resultant intramural hematoma and/or intimal flap can cause substantial luminal narrowing, leading to myocardial ischemia and infarction. Once considered rare, SCAD is now thought to be the cause of up to 4% of cases of ACS and up to 35% of cases of ACS in women younger than of 50 years of age. 4,5 Furthermore, there is evidence that the incidence of SCAD has increased during the past decades. 6

Look beyond the Heart: Extracoronary Vascular Manifestations of Spontaneous Coronary Artery Dissection

“…6 Additionally, Benson et al reported significant tortuosity in the carotid arteries such as a kink, loop, coil, or a retropharyngeal or retrojugular course in 46% of patients. 2 These findings have been reported in other studies as well. McNair et al, 3 similarly, showed that FMD was highly prevalent in the SCAD population (63%), with similar rates of carotid (38%) and renal (50%) FMD when imaged.…”

“…Similar to prior studies, there was a low prevalence of common cardiovascular risk factors, hypertension and hyperlipidemia (both 33%), compared with patients with atherosclerotic MI. [2][3][4] Prior studies with a thorough screening of head-to-pelvis imaging with either high-resolution CTA or MR angiography or conventional angiography have reported a .50% prevalence of concomitant multifocal FMD. 1,[3][4][5] Not surprisingly, Benson et al 2 corroborated the known association between FMD and SCAD because 50.5% of patients were found to have FMD in at least 1 noncoronary arterial bed.…”

2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

“…16,17 SCAD may be a manifestation of an underlying arteriopathy. 1,13,16,17 Pregnancy-associated SCAD has a worse prognosis than SCAD in the absence of pregnancy. 1,12,16,17 Conservative medical management of the acute event is favored, but selected unstable patients may require percutaneous or surgical revascularization.…”

“…The true prevalence of these disorders is unclear because reports are based on screening rates between 30% and 80%. 1-4,7,10,13–15 Table 14 lists screening questions that may point toward an underlying vasculopathy and, together with a detailed vascular physical examination, may facilitate a patient-clinician discussion about benefits and risks of imaging extracoronary vascular beds. 16 Although some cerebral aneurysms detected by screening have been large enough to warrant intervention, no studies to date show that screening for underlying arteriopathies changes patient treatment or patient outcomes.…”