Spontaneous coronary artery dissection: not always so benign

Extract

A 38-year-old woman presented a non-ST elevation myocardial infarction. Coronary angiography (CAG) revealed a nonsignificant lesion in the obtuse marginal branch (OM) with abrupt calibre recovery and normal distal flow (A1), suggesting a type 3 spontaneous coronary artery dissection (SCAD). The initial conservative management was chosen. Coronary computed tomography (CCT) showed wall thickening in the OM, consistent with intramural haematoma (IMH), without IMH in the left main coronary artery (LMCA) (A2). She was discharged with single antiplatelet therapy, but was readmitted 24 h later with chest pain. Repeat CAG showed severe LMCA narrowing due to IMH extension (B1), confirmed by intravascular ultrasound, which revealed extensive IMH from the LMCA to the distal OM (B2, TL: true lumen, FL: false lumen). A drug-eluting stent was placed from the LMCA to the proximal left circumflex and an IMH fenestration with a cutting balloon was performed in the OM. Subsequently, the patient had a good clinical course.