Acute Anterior STEMI in Multivessel Spontaneous Coronary Dissections

J INVASIVE CARDIOL 2020;32(6):E176.

Key words: cardiac imaging, coronary dissection

A 38-year-old, hypertensive female smoker was admitted for prolonged chest pain. Clinical history included previous treatment of mid-cerebral artery aneurysm. Electrocardiogram showed sinus rhythm and 6 mm ST elevation in the anterior leads. Coronary angiogram showed total occlusion of the ostial left anterior descending (LAD) artery and a dual lumen involving the left main (LM) with a huge hematoma compressing the lumen (Figure 1A), as confirmed by intravascular ultrasound (IVUS) (Figures 1B-1C). A highly supportive 0.014˝ hydrophilic guidewire was passed to the LAD, obtaining suboptimal flow restoration in a first diagonal branch (D1) due to type F dissection. Two drug-eluting stents were deployed in the proximal LAD-D1, followed by LM stenting to fix the severe dissection and avoid retrograde false lumen propagation in the left circumflex. TIMI 3 flow was restored with a residual non-flow limiting dissection at the distal LAD (Figure 1D).  

Spontaneous coronary artery dissection (SCAD) comprises 0.2%-4% of all acute coronary syndromes, and up to 8%-35% among young women. Multivessel SCAD is unusual. Coronary revascularization remains appropriate for unstable patients or those with compromised coronary blood flow, despite inconsistent data favoring percutaneous over surgical revascularization. Additionally, IVUS probe advancement and its retrieval could precipitate a dramatic progression of SCAD both distally and proximally to its original site.

From Centro Cardiologico Monzino, IRCCS, Milano, Italy.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein. 

The authors report that patient consent was provided for publication of the images used herein.

Manuscript accepted October 2, 2019.

Address for correspondence: Daniela Trabattoni, MD, Centro Cardiologico Monzino, IRCCS, Via Carlo Parea 4-20138 Milan, Italy. Email: daniela.trabattoni@ccfm.it