Advances in the Management of Spontaneous Coronary Artery Dissection (SCAD): A Comprehensive Review

Abstract

Spontaneous coronary artery dissection (SCAD) is a rare but significant cause of acute coronary syndrome (ACS), primarily affecting young women, often during pregnancy. Despite its rarity, SCAD poses challenges due to limited evidence on management strategies. This review examines the current state of art of SCAD management, integrating interventional and clinical insights from recent studies. The epidemiology of SCAD is related to its elusive nature, representing only a small fraction of ACS cases, while certainly underestimated. Proposed risk factors include genetic, hormonal, and environmental influences. Angiographic classification may help in SCAD diagnosis, but confirmation often relies on intracoronary imaging. Conservative management constitutes the primary approach, showing efficacy in most cases, although optimal antiplatelet therapy (APT) remains debated due to bleeding risks associated with intramural hematoma. Revascularization is reserved for high-risk cases, guided by angiographic and clinical criteria, with a focus on restoring flow rather than resolving dissection. Interventional strategies emphasize a minimalist approach to reduce complications, utilizing techniques such as balloon dilation and stent placement tailored to individual cases. Long-term outcomes highlight the risk of recurrence, necessitating vigilant follow-up and arrhythmic risk assessment, particularly in patients presenting with ventricular arrhythmias. In conclusion, SCAD management always represents a challenge for the physician, both from a clinical and interventional point of view. Recent clinical evidence and a multidisciplinary approach are vital for optimizing patient outcomes and preventing recurrence. This review offers a concise framework for navigating the complexities of SCAD management in clinical practice and proposes an algorithm for its management.

Keywords: acute coronary syndrome (ACS); antiplatelet therapy; fibromuscular dysplasia; myocardial infarction; percutaneous coronary intervention (PCI); pregnancy-associated; spontaneous coronary artery dissection (SCAD); women.

Fig. 1.

Angiographic classification of spontaneous coronary artery dissection (SCAD).

Fig. 2.

Case 1: Woman, 56 yo, presenting with acute myocardial infarction without ST-segment elevation (NSTEMI). (A) Angiographic presentation (type 1) SCAD of the proximal right coronary artery (RCA) with TIMI 1 flow. (B) Percutaneous coronary intervention (PCI) with implantation of a single Everolimus Eluting Stent due to the angiographic involvement of the proximal segment of RCA. TIMI, thrombolysis in myocardial infarction.

Fig. 3.

Case 2: Man, 51 yo, presenting with STEMI with evidence of SCAD of the left main involving also proximal left anterior descending artery (LAD) and circumflex artery (Cx), confirmed at intravascular ultrasound (IVUS) imaging. Given the young age and the need for an urgent interventional treatment a hybrid approach with bioresorbable vascular scaffolds (BVS) and single drug-eluting stent (DES) on left main (LM) was adopted.

Fig. 4.

Case 3: Woman, 52 yo, presenting with NSTEMI, on the way to the emergency department an episode of ventricular fibrillation treated with a single direct current (DC) shock. On admission persistence of chest pain unresponsive to nitrate therapy, normal ECG and ipokinesia of the antero-lateral wall at echo: urgent coronary angiography was indicated. (A) At coronary angiography SCAD of medium and distal LAD, confirmed with intracoronary imaging using optical coherence tomography (OCT) with evidence of outside-in mechanism (absence of intimal flap). (B) Due to the clinical instability (ventricular fibrillation (VF) before admission and refractory pain) an interventional strategy was chosen: a short single drug-eluting stent (DES) was deployed to fix the proximal cap of the dissection to prevent retrograde expansion. Consecutive only balloon angioplasties were performed to break the vessel walls and empty the intramural haematoma. POBA, plain only balloon angioplasty; NSTEMI, non ST-segment elevation myocardial infarction; ECG, electrocardiogram; SCAD, spontaneous coronary artery dissection; LAD, left anterior descending artery.

Fig. 5.

Case 4: Woman, 64 yo, presenting with an anterior STEMI. (A) At coronary angiogram, there was evidence of type 1 SCAD of the left main (LM) coronary artery (yellow arrow). (B) Due to the clinical presentation an interventional strategy was chosen and two non-polymeric wires were put in the Cx and LAD, complicated by multiple dissections of the proximal vessels (red arrows). (C) A hybrid strategy of DES+BVS was chosen to avoid full metal stenting. STEMI, acute myocardial infarction with ST-segment elevation; SCAD, spontaneous coronary artery dissection; Cx, circumflex artery; LAD, left anterior descending artery; DES, drug-eluting stent; BVS, bioresorbable vascular scaffolds.

Fig. 6.

(Central Figure)—Therapeutic algorithm for SCAD management. SCAD, spontaneous coronary artery dissection; SAPT, single antiplatelet therapy; DAPT, dual antiplatelet therapy; IVUS, intravascular ultrasound; OCT, optical coherence tomography; LM, left main; TIMI, thrombolysis in myocardial infarction; PCI, percutaneous coronary intervention.