Chronic Spontaneous Coronary Artery Dissection: A Case Report Utilizing Coronary Physiology and Optical Coherence Tomography for Diagnosis and Management.
TL;DR
Combining resting coronary physiology with optical coherence tomography provided complementary physiological and anatomical information that guided the intervention in a chronic, remodeled dissection-an approach that may be valuable if recurrent symptoms or ventricular dysfunction complicate SCAD follow-up, provided that pressure indices are interpreted cautiously.
Abstract
Spontaneous coronary artery dissection (SCAD) is a rare, non-atherosclerotic cause of acute coronary syndrome that disproportionately affects women without traditional cardiovascular risk factors, although it can also occur in patients with coexisting atherosclerotic risk factors. Chronic SCAD is uncommonly reported, and reassessing a previously dissected vessel raises specific diagnostic and therapeutic challenges. A 59-year-old woman with hypertension and diabetes had a spontaneous dissection of the proximal LAD, presenting as an NSTEMI managed conservatively. One year later, at 60 years of age, she presented with worsening angina and a left ventricular ejection fraction of 49%. Repeat coronary angiography confirmed the known dissection, with moderate true-lumen stenosis and a severe ostial first diagonal lesion arising from the true lumen. Resting full-cycle ratio (RFR) in the true lumen of the LAD was 0.82-a clearly ischaemic value. Optical coherence tomography showed a recanalized dissection with a persistent dual-lumen appearance, severe proximal calcification, a lipid-rich atheroma within the dissected segment, and post-dissection negative remodeling. Percutaneous coronary intervention with a drug-eluting stent and post-dilation (balloon sized 1:1 to the true-lumen diameter) reduced, but did not eliminate, the false lumen, with a final RFR of 0.88 and TIMI 3 flow. At 1-year follow-up, she remained free of angina, with an angiographic appearance similar to the immediate post-procedural result. Combining resting coronary physiology with optical coherence tomography provided complementary physiological and anatomical information that guided the intervention in a chronic, remodeled dissection-an approach that may be valuable if recurrent symptoms or ventricular dysfunction complicate SCAD follow-up, provided that pressure indices are interpreted cautiously.