Percutaneous coronary intervention in recurrent spontaneous coronary artery dissection: a case report

Abstract

Background: Spontaneous coronary artery dissection (SCAD) is an infrequent but potentially life-threatening condition in patients with acute myocardial infarction. Conservative medical therapy is recommended in patients with SCAD. However, very little evidence exists in the management of recurrent SCAD when conservative medical therapy fails.

Case summary: A 48-year-old woman presented with non-ST-elevation myocardial infarction (NSTEMI) on a background of cigarette smoking. Her coronary angiogram showed the first diagonal artery (D1) and right marginal branch (RM) occlusion with angiographic appearance that is consistent with SCAD. She was medically managed. She represented 2 months later with another NSTEMI, and her coronary angiogram showed healing SCAD in the D1 and RM, but a new SCAD in the first obtuse marginal artery (OM1). She was managed medically. She represented 4 months later complaining of angina every 2 days. This time her coronary angiogram showed healed SCAD in OM1 and RM, but the recurrence of SCAD in D1. Given that she had recurrent events despite medical therapy, we decided to proceed with percutaneous coronary intervention (PCI) to D1. She presented with an atypical chest pain 10 months later and her coronary angiogram showed complete healing of all coronary arteries and a patent stent in D1. She has remained symptom free.

Discussion: The management of SCAD is contentious given the lack of randomized clinical trials to assess optimal treatment strategy. In most patients with SCAD, conservative medical therapy is recommended after the diagnosis is secured. We believe that PCI may be beneficial in patients with recurrent SCAD.

Keywords: Acute coronary syndrome; Case report; Percutaneous coronary intervention; Spontaneous coronary artery dissection.

Figure 1

First coronary angiogram. (A) Spontaneous coronary artery dissection in first diagonal artery and (B) spontaneous coronary artery dissection in right marginal branch.

Figure 2

Second coronary angiogram. (A) Healing spontaneous coronary artery dissection in first diagonal artery; (B) healed spontaneous coronary artery dissection in right marginal branch; and (C) new spontaneous coronary artery dissection in obtuse marginal artery.

Figure 3

Third coronary angiogram. (A) Healed spontaneous coronary artery dissection in obtuse marginal artery; (B) Recurrent spontaneous coronary artery dissection in first diagonal artery; and (C) post-percutaneous coronary intervention in diagonal artery.