Spontaneous Coronary Artery Dissection: Efficient Clinical Outcome through Percutaneous Coronary Intervention

A 70 years-old male with a history of diabetes mellitus and hypertension, presented an acute squeezing chest tight of 5 hours duration in precordium after emotional stress. He was admitted to emergency department with blood pressure 171/100 mmHg. Electrocardiogram (ECG) showed frequent ventricular premature contractions and complete left bundle branch block which did not happen before. Laboratory examination showed elevated cardiac Troponin I (0.83 μg/L reference range, 0 to 0.15μg per liter) Creatine Kinase (268 U/L reference range, 30 to 170 IU per liter) and Creatine Kinase isoenzyme MB (31 U/L reference range, 0 to 25 IU per liter). Pharmacological management were included nitrate (Isosorbide mononitrate and glonoin) before primary percutaneous coronary intervention (PCI), His coronary angiogram showed a significant about 15mm lesion, dissection at the proximal left anterior descending artery(LAD) (Figure1) and diffuse severe stenosis in middle part of right coronary artery (RCA). There were no signs of dissection in the left circumflex coronary (LCx). Our strategy was combining pharmacological management and PCI which mean implanting a stent in the dissection of LAD. The procedure of cardiac catheterization was supported by intraaortic balloon pump (IABP) and temporary pacemaker (TPM), considering the patient with frequent ventricular premature and heart failure [ejection fraction 28% detected by transthoracic echocardiogram (TTE)]. Firstly a 40 ml IABP was implanted in aorta with adjusted counterpulsation pressure 110 to 130mmHg. Then TPM was transported in the right ventricular apex with 60 t/min setted. A Stent (4.0×24mm) was successfully implanted after balloon dilated from the LAD near end. Repeat angiography revealed that the LAD dissection noted earlier was resolved and far-end flowing blood improved after 30min observation. The patient continued the therapy by treating dual anti-platelet (oral aspirin 100mg and clopidogrel 75mg), blood pressure controlled (oral perindopri 2mg), and blood sugar controlled. After 1 week observation, we decided to implant two Stents (3.5×30mm 4.0×18mm) in the RCA to improve the far-end flowing (Figure 3). Meanwhile we did a angiography which also showed LAD dissection disappeared and no stenosis caused again (Figure 2). The patient did not complain discomfort through the procedure. He was maintained dual anti-platelet blood pressure and blood sugar controlled after revascularization. TTE showed a nearly normal ejection fraction (48%) after 2 years of following up. Spontaneous coronary artery dissection (SCAD) is a rare myocardial ischemic disease that threatens patients’ life. Various risk factors are associated with SCAD, such as smoking, severe hypertension and psychological reasons. Considering the formation of dissection, SCAD can be divided into intimal tear type or intraluminal hemorrhage type. The clinical presentation of SCAD depends on the extent and severity of progression of dissection and may present as unstable angina, acute myocardial infarction, ventricular arrhythmias or asymptom. Treatment of SCAD usually includes percutaneous coronary intervention (PCI), bypass graft surgery or medical therapy depending on the range of dissection. Herein, we report a 70 years-old male diagnosed with dissection in the left anterior descending artery by coronary arteriography. Despite the patient’s exposure to the ventricular arrhythmias, he had a good prognosis and survived at 2 years of following up. We found PCI treatment is suitable for the patient who had SCAD.