The Use of Cutting Balloons in Published Cases of Acute Coronary Syndrome Caused by Spontaneous Coronary Artery Dissection

Abstract

Spontaneous coronary artery dissection (SCAD) is a non-traumatic, non-atherosclerotic layering of the coronary artery wall due to the presence of a subintimal hematoma or an intimal tear with the creation of a false lumen that compresses the true lumen and restricts or obstructs the flow. Patients with SCAD and preserved coronary flow are treated conservatively according to the general recommendations. However, percutaneous coronary intervention should be considered in patients with artery occlusion and/or refractory ischemia. Stenting is associated with increased risks comprising stenting in the false lumen, in-stent thrombosis, and/or stent malappositon as well as antegrade or retrograde propagation of the intramural hematoma. Intracoronary imaging is of great value both for the diagnosis and treatment of SCAD. There is rising scrutiny on the use of cutting balloons in acute coronary syndrome caused by SCAD. The idea of using cutting balloons is to fenestrate the intima and drain the intramural hematoma. Our review presents an analysis of 17 published cases of cutting balloon (CB) use in SCAD. What is encouraging is that of the 12 published cases, in 11 Thrombolysis in Myocardial Infarction (TIMI) 3 flow was established with this technique, and TIMI 2 flow in one, without subsequent stent implantation. Four patients received a stent after the CB use, while one patient underwent CB angioplasty after hematoma propagation caused by stent implantation. In all cases, patients were asymptomatic at follow-up, with TIMI 3 flow.

Keywords: acute coronary syndrome; cutting balloon; spontaneous coronary artery dissection.

Fig. 1.

An algorithm of suggested treatment procedure for SCAD. SCAD, spontaneous coronary artery dissection; IVUS, intravascular ultrasound; OCT, optical coherent tomography; TIMI 3, Thrombolysis In Myocardial Infarction 3.

Fig. 2.

A schematic presentation of CB application. (A) The subintimal hematoma compresses the true lumen restricting blood flow. (B) Cutting balloon deployed on the site of the subintimal hematoma causing multiple fenestrations along the intima. (C) The fenestrations allow the blood to flow out from the false lumen tehereby decompressing the true lumen and improving blood flow. CB, cutting balloon.