Author + information
- Yoshimasa Tsurumaki1
Patient initials or identifier number
A 34-year-old woman
Relevant clinical history and physical exam
【History of present illness】
A 34-year-old woman attended our Emergency department complaining of chest pain with cold sweat and nausea.
【Past history・Medication・Allergy・Family history】
No remarkable findings
Smoking 1 pack per day Alcohol occasion drinker
Consciousness clear HR 115/min reg BP 155/104mmHg
SpO2 100% (room air) BT 36.7°C
Other physical examination was no remarkable findings
Relevant test results prior to catheterization
The initial electrocardiogram revealed V1-V4 ST-segment elevation and elevated cardiac enzymes (CK/CK-MB 480/43 U/L, troponin T was positive). Transthoracic echocardiography revealed ant-wall akinesis. We performed emergent CAG with a diagnosis of acute myocardial infarction.
Relevant catheterization findings
The coronary angiography showed moderate stenosis in the mid segment of LAD. IVUS revealed a true lumen and false lumen, in the distal segment of the LAD, We conformed coronary dissection with IVUS.
In the initial event, the mid segment of the left anterior descending artery was spontaneous dissected, which was confirmed by coronary angiography, intracoronary ultrasound. We performed PCI and deployed two drug eluting stents. In the second event, the right coronary artery was spontaneously dissected from distal to ostium. While she had been ongoing ischemia and hemodynamic compromise, we performed PCI and deployed drug eluting stents sequentially from distal to ostium. In this case, both PCI propagated dissection by stenting due to fragility of the vessel wall.
PCI with SCAD is often technically challenging in part due to fragility of the vessel wall. Any instrumentation (wiring, angioplasty, or stenting) can propagate dissection and occlude side branches. In addition, dissections often are extensive, requiring long stents with high likelihood of subsequent in-stent restenosis. Furthermore, temporal resolution of intramural hematoma in previously stented segments may increase the risk of late stent malapposition and stent thrombosis. Thus, PCI should only be pursued when there is a strong clinical indication.