Korean Circ J.  2013 Jul;43(7):491-496. 10.4070/kcj.2013.43.7.491.

Spontaneous Coronary Artery Dissection Mimicking Coronary Spasm Diagnosed by Intravascular Ultrasonography

• Chung H
• Lee SJ
• Park JK
• Choi IS
• Won HY
• Kim S
• Cha JJ
• Lee BK

• KMID: 2145506
• DOI: http://doi.org/10.4070/kcj.2013.43.7.491

Abstract

Spontaneous coronary artery dissection (SCAD) is a rare and occasionally life-threatening cause of acute coronary syndrome. Patients may present with clinical scenarios ranging from angina pectoris to cardiogenic shock to sudden cardiac death, and it may be a potentially life-threatening condition if not recognized. However, its etiology, pathophysiology and optimal therapeutic strategies have not been well understood. SCAD is diagnosed on the basis of coronary angiography, but complementary techniques as such intravascular ultrasound (IVUS) and optical coherence tomography should be considered for diagnostic clarification where appropriate. Likewise, the selection of treatment strategy depends upon the clinical manifestation, location and the extent of dissection and amount of ischemic myocardium at risk. Herein, we present the case of a 35-year-old woman who presented with acute myocardial infarction. She was diagnosed by IVUS with spontaneous diffuse dissection of the left anterior descending artery without atheroma, treated with percutaneous coronary stenting, and had a favorable clinical course and was discharged on medical therapy.

Keyword

Coronary artery dissection, spanteneous; Ultrasonography, interventional; Coronary vasospasm

MeSH Terms

Acute Coronary Syndrome
Angina Pectoris
Arteries
Coronary Angiography
Coronary Vasospasm
Coronary Vessels
Death, Sudden, Cardiac
Female
Humans
Myocardial Infarction
Myocardium
Plaque, Atherosclerotic
Shock, Cardiogenic
Spasm
Stents
Tomography, Optical Coherence
Ultrasonography, Interventional

Figure

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  Fig. 1 Electrocardiogram showing non specific T wave inversion in lead lll, aVF.

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  Fig. 2 Coronary angiogram imaging, showing RAO cranial view of the patient LAD. A: long, smooth narrowed lesion extending from the bifurcation point to mid LAD; the length of the narrowed lesion is marked by arrows. B: after intracoronary nitroglycerine infusion, the luminal narrowing of the mid LAD improved slightly, but not completely. RAO: right anterior oblique, LAD: left anterior descending artery.

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  Fig. 3 A: IVUS imaging before (A) and after (B) coronary stenting, and longitudinal imaging before coronary stenting (C). 1: proximal part of dissection. The intima and media are separated from the adventitia and compressed by an echolucent, probably RBC-poor, voluminous huge hematoma. There are two apparent echogenic tram tract like lines, representative of internal and external elastic lamina (A1). This lesion is covered by 3.0×28 mm XiencePrime stent (B1). 2: the most stenotic site on the angiogram. The true lumen is nearly obliterated by echogenic, probably RBC-rich, hematoma on IVUS (A2). This lesion is covered by 2.5×23 mm XiencePrime stent (B2). 3: distal normal segment of the m-LAD showing no atherosclerosis or dissection (A3). Distal stent lands at this normal segment (B3). 4: normal segment of the m-LAD showing just distal part of stent before (A4) and after (B4) coronary stenting. IVUS: intravascular ultrasound, LAD: left anterior descending artery, FL: false lumen, TL: true lumen.

Reference

1. Almeda FQ, Barkatullah S, Kavinsky CJ. Spontaneous coronary artery dissection. Clin Cardiol. 2004; 27:377–380.

2. Pretty HC. Dissecting aneurysm of coronary artery in a woman aged 42. Br Med J. 1931; 1:667–669.

3. Hering D, Piper C, Hohmann C, Schultheiss HP, Horstkotte D. [Prospective study of the incidence, pathogenesis and therapy of spontaneous, by coronary angiography diagnosed coronary artery dissection]. Z Kardiol. 1998; 87:961–970.

4. Desai S, Sheppard MN. Sudden cardiac death: look closely at the coronaries for spontaneous dissection which can be missed. A study of 9 cases. Am J Forensic Med Pathol. 2012; 33:26–29.

5. Tweet MS, Hayes SN, Pitta SR, et al. Clinical features, management, and prognosis of spontaneous coronary artery dissection. Circulation. 2012; 126:579–588.

6. Adlam D, Cuculi F, Lim C, Banning A. Management of spontaneous coronary artery dissection in the primary percutaneous coronary intervention era. J Invasive Cardiol. 2010; 22:549–553.

7. Gonzalez JI, Hill JA, Conti CR. Spontaneous coronary artery dissection treated with percutaneous transluminal angioplasty. Am J Cardiol. 1989; 63:885–886.

8. Maehara A, Mintz GS, Castagna MT, et al. Intravascular ultrasound assessment of spontaneous coronary artery dissection. Am J Cardiol. 2002; 89:466–468.

9. Paraskevaidis S, Theofilogiannakos EK, Chatzizisis YS, et al. Spontaneous dissection of right coronary artery manifested with acute myocardial infarction. Open Cardiovasc Med J. 2010; 4:178–180.

10. Almafragi A, Convens C, Heuvel PV. Spontaneous healing of spontaneous coronary artery dissection. Cardiol J. 2010; 17:92–95.

11. Borczuk AC, van Hoeven KH, Factor SM. Review and hypothesis: the eosinophil and peripartum heart disease (myocarditis and coronary artery dissection)--coincidence or pathogenetic significance? Cardiovasc Res. 1997; 33:527–532.

12. Robinowitz M, Virmani R, McAllister HA JrU. Spontaneous coronary artery dissection and eosinophilic inflammation: a cause and effect relationship? Am J Med. 1982; 72:923–928.

13. Jorgensen MB, Aharonian V, Mansukhani P, Mahrer PR. Spontaneous coronary dissection: a cluster of cases with this rare finding. Am Heart J. 1994; 127:1382–1387.

14. Arnold JR, West NE, van Gaal WJ, Karamitsos TD, Banning AP. The role of intravascular ultrasound in the management of spontaneous coronary artery dissection. Cardiovasc Ultrasound. 2008; 6:24.

15. Lerakis S, Manoukian S, Martin RP. Transesophageal echo detection of postpartum coronary artery dissection. J Am Soc Echocardiogr. 2001; 14:1132–1133.

16. Regar E, Ligthart J, Bruining N, van Soest G. The diagnostic value of intracoronary optical coherence tomography. Herz. 2011; 36:417–429.

17. Manghat NE, Morgan-Hughes GJ, Roobottom CA. Spontaneous coronary artery dissection: appearance and follow-up on multi-detector row CT coronary angiography. Clin Radiol. 2005; 60:1120–1125.

18. Mortensen KH, Thuesen L, Kristensen IB, Christiansen EH. Spontaneous coronary artery dissection: a Western Denmark Heart Registry study. Catheter Cardiovasc Interv. 2009; 74:710–717.

19. Vanzetto G, Berger-Coz E, Barone-Rochette G, et al. Prevalence, therapeutic management and medium-term prognosis of spontaneous coronary artery dissection: results from a database of 11,605 patients. Eur J Cardiothorac Surg. 2009; 35:250–254.

20. Shamloo BK, Chintala RS, Nasur A, et al. Spontaneous coronary artery dissection: aggressive vs. conservative therapy. J Invasive Cardiol. 2010; 22:222–228.