JACC: CARDIOVASCULAR INTERVENTIONS
VOL. 7, NO. 7, 2014
ª 2014 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION
ISSN 1936-8798/$36.00
PUBLISHED BY ELSEVIER INC.
http://dx.doi.org/10.1016/j.jcin.2013.12.207
IMAGES IN INTERVENTION
Multivessel Spontaneous Coronary Artery Dissection Mimicking Atherosclerosis Mathieu Lempereur, MD, Kenneth Gin, MD, Jacqueline Saw, MD Vancouver, British Columbia, Canada
A 54-year-old overweight post-menopausal woman with hypertension was admitted with prolonged (>12-h) chest pain following a very stressful work week of litigation. An electrocardiogram showed T-wave inversion anterolaterally, with a peak troponin I level of 1.67 mg/l. Coronary angiography the next day showed multivessel disease resembling atherosclerosis. She had severe diffuse disease in the first diagonal, first obtuse marginal (OM1), and right posterior descending artery (PDA), and moderate diffuse disease in the mid-left anterior descending (LAD) artery (Fig. 1, Online Videos 1, 2, and 3). Given the clinical suspicion of spontaneous coronary artery dissection (SCAD), optical coherence tomography (OCT) was performed. Surprisingly, this showed SCAD with intramural hematoma associated with a thickened and bright intima in the LAD (Fig. 1). Intramural hematoma was also seen in the OM1, diagonal, and PDA stenoses. Classic “string-of-beads” fibromuscular dysplasia (FMD) was visualized in both the renal and external iliac arteries (Fig. 2). She also developed blurred right vision in-hospital and was found to have spontaneous right vertebral artery dissection, with cerebrovascular FMD. She was managed conservatively and discharged in good condition. This case highlights the challenge of diagnosing SCAD on coronary angiography alone, which explains the underdiagnosis and underappreciation of SCAD in women presenting with myocardial infarction. Even though her coronary angiogram (especially the LAD) was compatible with an atherosclerotic appearance, a high clinical index of suspicion in this case (young woman, significant emotional stress, and presence of FMD) led to OCT, which showed simultaneous
From Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada. The authors have reported that they have no relationships relevant to the contents of this paper to disclose. Manuscript received November 26, 2013; accepted December 5, 2013.
Figure 1. Coronary Angiogram and OCT Images (A) Cranial projection showing moderate stenosis in the mid-left anterior descending coronary artery (LAD) (arrow), and severe stenosis in the first diagonal artery (arrow). This is best seen on Online Video 1. (B) Right anterior oblique caudal projection showing severe stenosis of the first obtuse marginal branch (arrow). See Online Video 2. (C) Left anterior oblique cranial projection showing severe stenosis of the right posterior descending artery (arrow). See Online Video 3. (D) Optical coherence tomography (OCT) of the LAD (arrow in A) showing intramural hematoma. (E) OCT of the first diagonal artery (arrow in A) showing intramural hematoma. (F) OCT of the first obtuse marginal artery (arrow in B) showing intramural hematoma. (G) OCT of the right posterior descending artery (arrow in C) showing intramural hematoma.
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Lempereur et al. Multivessel Spontaneous Coronary Dissection
JACC: CARDIOVASCULAR INTERVENTIONS, VOL. 7, NO. 7, 2014 JULY 2014:e87–8
4-vessel SCAD (first-ever report to our knowledge). In addition, she had simultaneous dissection in a noncardiac artery (vertebral) also related to FMD. We would like to stress that a large proportion of SCAD have the angiographic appearance of diffuse and typically smooth stenosis that is due to intramural hematoma (as previously described by our group and others) (1,2), and do not have the pathognomonic multiple radiolucent wall stains. Interventionists should strongly consider adjunctive intracoronary imaging for suspected SCAD. Reprint requests and correspondence: Dr. Jacqueline Saw, Vancouver General Hospital, University of British Columbia, 2775 Laurel Street, Level 9, Vancouver, British Columbia V5Z1M9, Canada. E-mail: [email protected]. REFERENCES
1. Saw J, Ricci D, Starovoytov A, Fox R, Buller CE. Spontaneous coronary artery dissection: prevalence of predisposing conditions including fibromuscular dysplasia in a tertiary center cohort. J Am Coll Cardiol Intv 2013;6:44–52. 2. Alfonso F, Paulo M, Gonzalo N, et al. Diagnosis of spontaneous coronary artery dissection by optical coherence tomography. J Am Coll Cardiol 2012;59:1073–9.
Key Words: fibromuscular dysplasia - myocardial infarction - spontaneous coronary artery - women. APPENDIX For supplemental videos, please see the online version of this article.
Figure 2. Pelvic and Renal Angiograms (A) Pelvic angiogram with digital subtraction showing string-of-beads fibromuscular dysplasia (FMD) changes of both iliac arteries. Patient also has FMD of the (B) right renal artery, and (C) left renal artery.
VOL. 7, NO. 7, 2014
ª 2014 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION
ISSN 1936-8798/$36.00
PUBLISHED BY ELSEVIER INC.
http://dx.doi.org/10.1016/j.jcin.2013.12.207
IMAGES IN INTERVENTION
Multivessel Spontaneous Coronary Artery Dissection Mimicking Atherosclerosis Mathieu Lempereur, MD, Kenneth Gin, MD, Jacqueline Saw, MD Vancouver, British Columbia, Canada
A 54-year-old overweight post-menopausal woman with hypertension was admitted with prolonged (>12-h) chest pain following a very stressful work week of litigation. An electrocardiogram showed T-wave inversion anterolaterally, with a peak troponin I level of 1.67 mg/l. Coronary angiography the next day showed multivessel disease resembling atherosclerosis. She had severe diffuse disease in the first diagonal, first obtuse marginal (OM1), and right posterior descending artery (PDA), and moderate diffuse disease in the mid-left anterior descending (LAD) artery (Fig. 1, Online Videos 1, 2, and 3). Given the clinical suspicion of spontaneous coronary artery dissection (SCAD), optical coherence tomography (OCT) was performed. Surprisingly, this showed SCAD with intramural hematoma associated with a thickened and bright intima in the LAD (Fig. 1). Intramural hematoma was also seen in the OM1, diagonal, and PDA stenoses. Classic “string-of-beads” fibromuscular dysplasia (FMD) was visualized in both the renal and external iliac arteries (Fig. 2). She also developed blurred right vision in-hospital and was found to have spontaneous right vertebral artery dissection, with cerebrovascular FMD. She was managed conservatively and discharged in good condition. This case highlights the challenge of diagnosing SCAD on coronary angiography alone, which explains the underdiagnosis and underappreciation of SCAD in women presenting with myocardial infarction. Even though her coronary angiogram (especially the LAD) was compatible with an atherosclerotic appearance, a high clinical index of suspicion in this case (young woman, significant emotional stress, and presence of FMD) led to OCT, which showed simultaneous
From Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada. The authors have reported that they have no relationships relevant to the contents of this paper to disclose. Manuscript received November 26, 2013; accepted December 5, 2013.
Figure 1. Coronary Angiogram and OCT Images (A) Cranial projection showing moderate stenosis in the mid-left anterior descending coronary artery (LAD) (arrow), and severe stenosis in the first diagonal artery (arrow). This is best seen on Online Video 1. (B) Right anterior oblique caudal projection showing severe stenosis of the first obtuse marginal branch (arrow). See Online Video 2. (C) Left anterior oblique cranial projection showing severe stenosis of the right posterior descending artery (arrow). See Online Video 3. (D) Optical coherence tomography (OCT) of the LAD (arrow in A) showing intramural hematoma. (E) OCT of the first diagonal artery (arrow in A) showing intramural hematoma. (F) OCT of the first obtuse marginal artery (arrow in B) showing intramural hematoma. (G) OCT of the right posterior descending artery (arrow in C) showing intramural hematoma.
e88
Lempereur et al. Multivessel Spontaneous Coronary Dissection
JACC: CARDIOVASCULAR INTERVENTIONS, VOL. 7, NO. 7, 2014 JULY 2014:e87–8
4-vessel SCAD (first-ever report to our knowledge). In addition, she had simultaneous dissection in a noncardiac artery (vertebral) also related to FMD. We would like to stress that a large proportion of SCAD have the angiographic appearance of diffuse and typically smooth stenosis that is due to intramural hematoma (as previously described by our group and others) (1,2), and do not have the pathognomonic multiple radiolucent wall stains. Interventionists should strongly consider adjunctive intracoronary imaging for suspected SCAD. Reprint requests and correspondence: Dr. Jacqueline Saw, Vancouver General Hospital, University of British Columbia, 2775 Laurel Street, Level 9, Vancouver, British Columbia V5Z1M9, Canada. E-mail: [email protected]. REFERENCES
1. Saw J, Ricci D, Starovoytov A, Fox R, Buller CE. Spontaneous coronary artery dissection: prevalence of predisposing conditions including fibromuscular dysplasia in a tertiary center cohort. J Am Coll Cardiol Intv 2013;6:44–52. 2. Alfonso F, Paulo M, Gonzalo N, et al. Diagnosis of spontaneous coronary artery dissection by optical coherence tomography. J Am Coll Cardiol 2012;59:1073–9.
Key Words: fibromuscular dysplasia - myocardial infarction - spontaneous coronary artery - women. APPENDIX For supplemental videos, please see the online version of this article.
Figure 2. Pelvic and Renal Angiograms (A) Pelvic angiogram with digital subtraction showing string-of-beads fibromuscular dysplasia (FMD) changes of both iliac arteries. Patient also has FMD of the (B) right renal artery, and (C) left renal artery.
