Assessment of extra-coronary peripheral arteriopathy in spontaneous coronary dissection: state of the art in non-invasive imaging techniques and future perspectives

Abstract

Spontaneous coronary artery dissection (SCAD) has been recognized as an important cause of acute coronary syndrome in women ≤ 50 years old, and up to 43% of pregnancy-associated myocardial infarction. SCAD has a strong association with extra-coronary arteriopathies, including either more common entities such as dissections, intracranial or other aneurysms, and extra-coronary and coronary arterial tortuosity or less common inherited vascular disorders such as Ehlers-Danlos syndrome, Marfan syndrome, and Loeys-Dietz syndrome, leading to the conclusion that systemic arterial disorders may underlie SCAD. Fibromuscular dysplasia is the most common extra-coronary vascular abnormality identified among these patients, also sharing a common genetic variant with SCAD. The American Heart Association, in a scientific statement regarding the management of SCAD, recommends that patients with SCAD should undergo additional evaluation with imaging techniques including either computed tomography angiography (CTA) or magnetic resonance angiography (MRA). MRA has been shown to have sufficient diagnostic accuracy in identifying extra-coronary arterial abnormalities, almost equal to CTA and conventional angiography. The aim of this review is to appraise the most recent important evidence of extra-coronary arteriopathy in the setting of SCAD and to discuss the strengths and weaknesses of various non-invasive imaging methods for screening of extra-coronary arteriopathies in patients with SCAD.

Keywords: computed tomography angiography; extra-coronary peripheral arteriopathy; fibromuscular dysplasia; magnetic resonance angiography; non-invasive imaging; spontaneous coronary artery dissection.

Graphical Abstract

Figure 1

Pathophysiology of spontaneous coronary artery dissection.

Figure 2

This diagram graphically depicts the timeline of an example study including full vascular screening using the gadobutrol bolus. CE-MRA, contrast-enhanced magnetic resonance angiography, 3D steady-state-free-precession (SSFP); EGE, early gadolinium enhancement; LGE, late gadolinium enhancement; SAX, short axis.

Figure 3

(A) Irregularities and focal dilatation in the external iliac arteries. (B) Small right vertebral artery focal dissection. (C) Tortuous right common iliac artery with mildly dilated middle and distal segments. (D) Tortuous distal abdominal aorta and iliac arteries with focal proximal dilation of the left common iliac artery. (E) Significant tapering at the origin of coeliac trunk. (F) Focal regions of stenosis and mild dilatation in the mid-course of the renal artery typical for fibromuscular dysplasia.

Figure 4

Advantages and disadvantages of each non-invasive imaging technique for identifying extra-coronary arteriopathies in patients with SCAD. (Left) Computed tomography angiography (CTA). (Right) Contrast-enhanced magnetic resonance angiography (CE-MRA).

Figure 5

Fibromuscular dysplasia in proximal renal artery; comparison between contrast-enhanced magnetic resonance angiography (A) and computed tomography angiography (B). Fibromuscular dysplasia in iliac artery; comparison between contrast-enhanced magnetic resonance angiography (C) and computed tomography angiography (D).

Figure 6

Clinical algorithm for the diagnosis and management of extra-coronary arteriopathies in the setting of SCAD.