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Unusual interventional treatment of spontaneous coronary artery dissection without stent implantation: a case series.

ABSTRACT:

Background

Spontaneous coronary artery dissection (SCAD) is a unique cause of myocardial infarction, and optimal treatment should be selected according to the ischaemic condition. Patients with ongoing ischaemia or haemodynamic instability may require revascularization. Cutting balloon (CB) angioplasty has been acknowledged as an option for revascularization. However, few observations of the coronary artery conditions after CB angioplasty in SCAD patients have been reported. Here, we demonstrate two cases in which we evaluated the angiographic morphology of targeted coronary arteries in the chronic phase after CB angioplasty.

Case summary

Patient 1 was a 46-year-old woman who presented at our hospital with chest pain. Electrocardiography suggested acute coronary syndrome and coronary angiography was performed. The coronary angiography and intravascular ultrasound (IVUS) examinations revealed SCAD in the left anterior descending artery (LAD). Revascularization with CB angioplasty was successful. Follow-up coronary angiography 15 months after the angioplasty showed no visible stenosis in the LAD. Accordingly, the patient no longer needed to antiplatelet therapy. Patient 2 was a 50-year-old woman who was transported to our hospital for ventricular tachycardia. Coronary angiography and IVUS revealed SCAD in the right coronary artery. Coronary flow was restored by CB angioplasty. Follow-up contrast-enhanced computed tomography angiography 36 months after angioplasty showed a healed appearance. Thus, she was able to discontinue antiplatelet therapy.

Discussion

Cutting balloon angioplasty may be a possible method to treat SCAD.

SUBMITTER: Fujita H

PROVIDER: S-EPMC8350351 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:ImportanceSpontaneous coronary artery dissection (SCAD) is a notable cause of acute coronary syndrome in women of childbearing age.ObjectiveTo test the hypothesis that pregnancy after SCAD is associated with recurrent SCAD.Design, setting, and participantsThree study designs were implemented: a case series of women with pregnancy after SCAD; a nested case-control study comparing patients with recurrent SCAD to matched controls without recurrent SCAD; and a cohort study. Women with SCAD who were of childbearing potential and enrolled into the Mayo Clinic SCAD Registry from August 30, 2011, to April 4, 2019, were included in the study. Patients with coronary dissections associated with iatrogenesis, trauma, or atherosclerosis were not enrolled.ExposuresPregnancy after SCAD.Main outcomes and measuresThe primary outcome was SCAD recurrence, defined as an acute coronary syndrome or cardiac arrest due to new SCAD. Other demographic measures collected included age, year of SCAD occurrence, and comorbidities.ResultsThe cohort included 636 women of childbearing potential. Twenty-three of those women had a total of 32 pregnancies after SCAD. The median (interquartile range) age of women with pregnancy after SCAD was 38 years (34-40 years), and 20 (87%) were White. In the nested case-control study, 92 cases of recurrent SCAD were matched to 158 controls. There was no significant difference in exposure to subsequent pregnancies in the women with recurrent SCAD as compared with matched controls (2 of 92 [2%] vs 13 of 158 [8%]; P = .06). In the overall cohort of 636 patients, recurrent SCAD was present in 122 patients with a Kaplan-Meier 5-year SCAD recurrence estimate of 14.8%. The Cox analysis showed no significant association between subsequent pregnancy and SCAD recurrence with a nonsignificant hazard ratio of 0.38 (95% CI, 0.09-1.6) when controlling for age at first SCAD, year of first SCAD, and fibromuscular dysplasia.Conclusions and relevanceThis study found that most women tolerated pregnancy and lactation after SCAD without evidence for increased risk of SCAD recurrence when compared with women with a history of SCAD who did not experience pregnancy. Although this study is reassuring and indicates complex contributors to SCAD recurrence, the results need to be interpreted prudently because of study selection bias and the small total number of women who became pregnant after SCAD. The notable hemodynamic changes that occur with pregnancy and severe presentation of pregnancy-associated SCAD are reasons for concern when considering pregnancy after SCAD.