Multivessel spontaneous coronary artery dissection involving the left main coronary artery: a case report

Abstract

Background: Spontaneous coronary artery dissection (SCAD) is an infrequent and often misdiagnosis of a non-atherosclerotic cause of acute coronary syndrome (ACS). It is an important cause of ACS in young women, responsible for up to 25% of all cases in women <50 years of age without cardiovascular risk factors. Clinical presentation ranges from ST-segment-elevation myocardial infarction (MI) to ventricular fibrillation and sudden death. The treatment of patients with SCAD is a challenge and the ideal management strategy has yet to be determined.

Case summary: A 42-year-old woman without family history of cardiac disease and neither traditional atherosclerotic risk factors presented to our centre with an anterior acute ST-segment-elevation MI secondary to multiple spontaneous dissections of the left main, anterior descending, and ramus intermedius coronary arteries. Stenting was performed in the left anterior descending coronary artery and left main coronary artery to resolve its occlusion. Fibromuscular dysplasia was confirmed via computed tomography angiography.

Discussion: More cases are now being identified of SCAD due to increased clinical index of suspicion, earlier use of invasive angiography, and intracoronary imaging in patients presenting with acute chest pain. Despite this, the absence of previous cardiovascular risk factors and the ignorance of this pathology delay the start of an adequate medical treatment and the performance of a cardiac catheterization. Prognostic data are limited, partly because of its underdiagnosis and lack of prospective studies, so its knowledge is necessary to improve the prognosis of these patients.

Keywords: Acute coronary syndrome; Case report; Fibromuscular dysplasia; Spontaneous coronary artery dissection.

Figure 1

Coronary angiogram in the right anterior oblique 25° and caudal 25° position. No coronary flow in left anterior descending coronary artery and ramus intermedius coronary artery.

Figure 2

Coronary angiogram in the right anterior oblique 25° and caudal 25° position. After guide wire passes through, it showed multiple radiolucent lumen suggestive of possible type I intimal dissection of the left anterior descending coronary artery involving the first diagonal branch artery, the ramus intermedius coronary artery with extension to the left main coronary artery.

Figure 3

Intravascular ultrasound showing dissection and intramural haematoma starting from the distal left main coronary artery and progressing into the ostium of the left anterior descending. Intramural haematoma (arrow) in the media of the arterial wall resulted in compression of the real lumen.

Figure 4

Right anterior oblique 25° caudal 25° view. A drug-eluting stent was successfully implanted over the dissection involving the left main artery and the proximal portion of the left anterior descending coronary artery. Normal blood flow was restored with no residual stenosis.