Canadian Journal of Cardiology 30 (2014) 1461.e1e1461.e3 www.onlinecjc.ca
Case Report
Spontaneous Coronary Artery Dissection Treated With Bioresorbable Vascular Scaffolds Guided by Optical Coherence Tomography James Cockburn, MD, BSc, MRCP, Warren Yan, FRACP, Ravinay Bhindi, PhD, FRACP, and Peter Hansen, PhD, FRACP Royal North Shore Hospital, Sydney, New South Wales, Australia
ABSTRACT
RESUM E
Spontaneous coronary artery dissection (SCAD) is an uncommon cause of acute coronary syndromes. We report the first case, to our knowledge, of SCAD in an active fit man. We treated this patient with novel bioresorbable vascular scaffold, guided by optical coherence tomography.
e de l’artère coronaire (DSAC) est une cause La dissection spontane rare de syndromes coronariens aigus. À notre connaissance, nous sentons le premier cas de DSAC chez un homme actif et en forme. pre ce patient à l’aide d’une nouvelle endoprothèse Nous avons traite sorbable en tomographie par cohe rence optique. vasculaire biore
Case Presentation A fit and active 43-year-old male triathlete was admitted with a 24-hour history of effort-related chest tightness, precipitated by bench pressing heavy weights 3 days previously. He had no cardiovascular risk factors, no history of connective tissue disease, and no history of recreational drug use. Examination was unremarkable. Twelve-lead electrocardiography demonstrated 1.0-mm inferolateral ST depression with T-wave inversion. High-sensitivity troponin was elevated at 166 ng/L (normal < 14 ng/L). A rheumatologic opinion was sought, and initial screening for connective tissue and autoimmune disease was negative (Supplemental Appendix S1). Transthoracic echocardiography showed septal hypokinesis with an ejection fraction of 55%. The patient underwent invasive risk stratification with diagnostic coronary angiography (DCA). DCA of the right radial artery demonstrated an absence of significant atherosclerotic disease but evidence of spontaneous coronary artery dissection involving the distal segment of the AV circumflex artery (Fig. 1A), with Thrombolysis In Myocardial Infarction (TIMI) I flow.
The decision was made to undertake further assessment of the vessel using optical coherence tomography (OCT), with the view to proceeding to percutaneous coronary intervention (PCI) if appropriate. Using an XB 3.5 6F guide, the AV circumflex vessel was wired using a Sion Blue wire (Asahi Intecc, Nagoya, Japan). The wire was placed in multiple small side branches to confirm that it was within the true lumen. OCT showed the dissection entry point, with evidence of a long segment of intramural hematoma within the false lumen (Fig. 2, A and B). The distal diameter was confirmed at 2.7 mm, the proximal diameter at 3.6 mm, and the lesion length at 39.3 mm. In view of the patient’s relatively young age, ongoing symptoms, and the fact that the values obtained for the size of the vessel and length of the lesion fit appropriately with the limited size and length of scaffold commercially available, the decision was made to undertake percutaneous coronary intervention (PCI) using bioresorbable ABSORB scaffolds (Abbott Vascular, Santa Clara, CA). A 2.5 18 mm scaffold was placed distally and slowly inflated (> 30 seconds) to a maximum pressure of 16 Atm. A 3.0 28 mm scaffold was then placed, minimizing the degree of overlap as much as possible. The scaffold was again slowly inflated and then dilated with a 3.5 12 NC TREK, (Abbott Vascular, Santa Clara, CA) to 14 Atm. This gave an excellent final angiographic result (Fig. 1B), and OCT confirmed that both scaffolds were well apposed, fully expanded, and covered all of the dissection (Fig. 2, C and D).
Received for publication March 13, 2014. Accepted June 17, 2014. Corresponding author: Dr James Cockburn, Royal North Shore Hospital, Reserve road, St Leonards, Sydney, New South Wales 2065, Australia. Tel.: þ61-2-9926-7111; fax: þ61-2-9926-7112. E-mail: [email protected] See page 1461.e3 for disclosure information.
http://dx.doi.org/10.1016/j.cjca.2014.06.025 0828-282X/Ó 2014 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.
1461.e2
Canadian Journal of Cardiology Volume 30 2014
Figure 1. Diagnostic coronary angiography. (A) Spontaneous coronary artery dissection involving a long segment of the mid to distal left circumflex coronary artery with complete occlusion of the vessel (arrows). (B) Left circumflex artery after bioresorbable vascular scaffold implantation.
Figure 2. Optical coherence tomography images. (A) Spontaneous coronary dissection, long axis view. (B) Spontaneous coronary dissection, short axis viewsdproximal, mid, and distal vessel, including diameters. (C) AV circumflex artery dissection after bioresorbable vascular scaffold (BVS) implantation, long axis view. (D) AV circumflex artery dissection after BVS implantation, short axis viewsdproximal, mid, and distal vessel.
Cockburn et al. Coronary Dissection Treated With BVS
He was treated with 12 months of dual-antiplatelet therapy and remained asymptomatic on clinical follow-up. Discussion Spontaneous coronary artery dissection (SCAD) is an uncommon event (incidence 0.1%-1.1%),1,2 and 80%-90% of cases involve women.1,2 The spectrum of presentation reflects the extent and severity of the dissection and varies from asymptomatic to acute coronary syndromes, ventricular arrhythmias, and sudden death.3 There are a number of associations with SCAD. These include coronary atherosclerosis (plaque inflammation and rupture intimal-medial disruption) and fibromuscular dysplasia. Rarely, it can occur during the peripartum period (eosinophilic infiltration and hormonal/hemodynamic changes). Intense spasm from cocaine use can cause increased shear stress, leading to SCAD. Other associations include hypertension (cystic medial necrosis), connective tissue disorders, eg, Marfan syndrome/Ehlers-Danlos syndrome, and vasculitides, eg, polyarteritis nodosa/systemic lupus erythematosus. Excessive exercise in which increased mechanical wall stress arises from the hyperdynamic state has also been described.1-3 Diagnosis of SCAD relies on imaging. DCA demonstrates a longitudinal thin radiolucent line as a result of flow in 2 separate lumens as well as haziness suggesting thrombus formation. However, DCA cannot directly visualize the vessel wall and so has limited sensitivity.3 Intravascular imaging techniques, such as intravascular ultrasonography or OCT,4,5 offer increased diagnostic accuracy. OCT is often preferred because its spatial resolution is on the order of 15 mm. OCT can aid subsequent management. Alfonso et al.5 found that OCT readily identified the double-lumen morphologic characteristic of SCAD, the entry tear, the circumferential and longitudinal extent of the tear, side branch involvement, compromise of the true lumen, and distribution of the false lumen. OCT was particularly helpful when there was suspicion of intramural hematoma. Using OCT to guide BVS implantation in SCAD is important because it helps guide scaffold sizing in a vessel that is smaller than its reference size in the absence of normal flow, as well as detailing lesion characteristics. This is important when using BVS because lesion preparation is key to adequate scaffold expansion (> 0.5 mm above scaffold size after dilation is contraindicated because of the risk of scaffold fracture). Management of SCAD can range from conservative medical therapy to PCI and rarely coronary artery bypass grafting. It should be tailored to the individual case according to both clinical features and angiographic features.1-3 Conservative therapy may suffice when the patient is asymptomatic, the dissection involves small or distal vessels, or
1461.e3
when coronary flow is preserved.2 Antiplatelet agents, b-blockers, and vasodilators are the mainstay of medical therapy.2 PCI is appropriate in the presence of ongoing refractory or recurrent ischemia, or hemodynamic instability. If PCI is undertaken, there must be careful consideration of scaffold expansion and length to avoid propagation of the dissection into unaffected coronary segments.3 When there is left main multivessel involvement or concomitant valve disease, surgical revascularization may be preferable.3 There are a number of potential advantages to using BVS in SCAD. BVS offers both drug elution and temporary scaffolding of the vessel, with the theoretical advantage of restoration of native vessel biomechanical characteristics (vessel vasomotion/adaptive shear stress/late luminal enlargement/late expansive remodelling). Conclusions SCAD is an uncommon cause of acute coronary syndromes. OCT is a useful diagnostic tool that also aids treatment. BVS may offer an alternative to metallic stents when PCI is considered. Disclosures The authors have no conflicts to disclose. References 1. Saw J, Ricci D, Starovoytov A, et al. Spontaneous coronary artery dissection: prevalence of predisposing conditions including fibromuscular dysplasia in a tertiary center cohort. JACC Cardiovasc Interv 2013;6: 44-52. 2. Tweet MS, Hayes SN, Pitta SR, et al. Clinical features, management, and prognosis of spontaneous coronary artery dissection. Circulation 2012;126:579-88. 3. Vrints CJ. Spontaneous coronary artery dissection. Heart 2010;96:801-8. 4. Maehara A, Mintz GS, Castagna MT, et al. Intravascular ultrasound assessment of spontaneous coronary artery dissection. Am J Cardiol 2002;89:466-8. 5. 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.
Supplementary Material To access the supplementary material accompanying this article, visit the online version of the Canadian Journal of Cardiology at www.onlinecjc.ca and at http://dx.doi.org/10. 1016/j.cjca.2014.06.025.
Case Report
Spontaneous Coronary Artery Dissection Treated With Bioresorbable Vascular Scaffolds Guided by Optical Coherence Tomography James Cockburn, MD, BSc, MRCP, Warren Yan, FRACP, Ravinay Bhindi, PhD, FRACP, and Peter Hansen, PhD, FRACP Royal North Shore Hospital, Sydney, New South Wales, Australia
ABSTRACT
RESUM E
Spontaneous coronary artery dissection (SCAD) is an uncommon cause of acute coronary syndromes. We report the first case, to our knowledge, of SCAD in an active fit man. We treated this patient with novel bioresorbable vascular scaffold, guided by optical coherence tomography.
e de l’artère coronaire (DSAC) est une cause La dissection spontane rare de syndromes coronariens aigus. À notre connaissance, nous sentons le premier cas de DSAC chez un homme actif et en forme. pre ce patient à l’aide d’une nouvelle endoprothèse Nous avons traite sorbable en tomographie par cohe rence optique. vasculaire biore
Case Presentation A fit and active 43-year-old male triathlete was admitted with a 24-hour history of effort-related chest tightness, precipitated by bench pressing heavy weights 3 days previously. He had no cardiovascular risk factors, no history of connective tissue disease, and no history of recreational drug use. Examination was unremarkable. Twelve-lead electrocardiography demonstrated 1.0-mm inferolateral ST depression with T-wave inversion. High-sensitivity troponin was elevated at 166 ng/L (normal < 14 ng/L). A rheumatologic opinion was sought, and initial screening for connective tissue and autoimmune disease was negative (Supplemental Appendix S1). Transthoracic echocardiography showed septal hypokinesis with an ejection fraction of 55%. The patient underwent invasive risk stratification with diagnostic coronary angiography (DCA). DCA of the right radial artery demonstrated an absence of significant atherosclerotic disease but evidence of spontaneous coronary artery dissection involving the distal segment of the AV circumflex artery (Fig. 1A), with Thrombolysis In Myocardial Infarction (TIMI) I flow.
The decision was made to undertake further assessment of the vessel using optical coherence tomography (OCT), with the view to proceeding to percutaneous coronary intervention (PCI) if appropriate. Using an XB 3.5 6F guide, the AV circumflex vessel was wired using a Sion Blue wire (Asahi Intecc, Nagoya, Japan). The wire was placed in multiple small side branches to confirm that it was within the true lumen. OCT showed the dissection entry point, with evidence of a long segment of intramural hematoma within the false lumen (Fig. 2, A and B). The distal diameter was confirmed at 2.7 mm, the proximal diameter at 3.6 mm, and the lesion length at 39.3 mm. In view of the patient’s relatively young age, ongoing symptoms, and the fact that the values obtained for the size of the vessel and length of the lesion fit appropriately with the limited size and length of scaffold commercially available, the decision was made to undertake percutaneous coronary intervention (PCI) using bioresorbable ABSORB scaffolds (Abbott Vascular, Santa Clara, CA). A 2.5 18 mm scaffold was placed distally and slowly inflated (> 30 seconds) to a maximum pressure of 16 Atm. A 3.0 28 mm scaffold was then placed, minimizing the degree of overlap as much as possible. The scaffold was again slowly inflated and then dilated with a 3.5 12 NC TREK, (Abbott Vascular, Santa Clara, CA) to 14 Atm. This gave an excellent final angiographic result (Fig. 1B), and OCT confirmed that both scaffolds were well apposed, fully expanded, and covered all of the dissection (Fig. 2, C and D).
Received for publication March 13, 2014. Accepted June 17, 2014. Corresponding author: Dr James Cockburn, Royal North Shore Hospital, Reserve road, St Leonards, Sydney, New South Wales 2065, Australia. Tel.: þ61-2-9926-7111; fax: þ61-2-9926-7112. E-mail: [email protected] See page 1461.e3 for disclosure information.
http://dx.doi.org/10.1016/j.cjca.2014.06.025 0828-282X/Ó 2014 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.
1461.e2
Canadian Journal of Cardiology Volume 30 2014
Figure 1. Diagnostic coronary angiography. (A) Spontaneous coronary artery dissection involving a long segment of the mid to distal left circumflex coronary artery with complete occlusion of the vessel (arrows). (B) Left circumflex artery after bioresorbable vascular scaffold implantation.
Figure 2. Optical coherence tomography images. (A) Spontaneous coronary dissection, long axis view. (B) Spontaneous coronary dissection, short axis viewsdproximal, mid, and distal vessel, including diameters. (C) AV circumflex artery dissection after bioresorbable vascular scaffold (BVS) implantation, long axis view. (D) AV circumflex artery dissection after BVS implantation, short axis viewsdproximal, mid, and distal vessel.
Cockburn et al. Coronary Dissection Treated With BVS
He was treated with 12 months of dual-antiplatelet therapy and remained asymptomatic on clinical follow-up. Discussion Spontaneous coronary artery dissection (SCAD) is an uncommon event (incidence 0.1%-1.1%),1,2 and 80%-90% of cases involve women.1,2 The spectrum of presentation reflects the extent and severity of the dissection and varies from asymptomatic to acute coronary syndromes, ventricular arrhythmias, and sudden death.3 There are a number of associations with SCAD. These include coronary atherosclerosis (plaque inflammation and rupture intimal-medial disruption) and fibromuscular dysplasia. Rarely, it can occur during the peripartum period (eosinophilic infiltration and hormonal/hemodynamic changes). Intense spasm from cocaine use can cause increased shear stress, leading to SCAD. Other associations include hypertension (cystic medial necrosis), connective tissue disorders, eg, Marfan syndrome/Ehlers-Danlos syndrome, and vasculitides, eg, polyarteritis nodosa/systemic lupus erythematosus. Excessive exercise in which increased mechanical wall stress arises from the hyperdynamic state has also been described.1-3 Diagnosis of SCAD relies on imaging. DCA demonstrates a longitudinal thin radiolucent line as a result of flow in 2 separate lumens as well as haziness suggesting thrombus formation. However, DCA cannot directly visualize the vessel wall and so has limited sensitivity.3 Intravascular imaging techniques, such as intravascular ultrasonography or OCT,4,5 offer increased diagnostic accuracy. OCT is often preferred because its spatial resolution is on the order of 15 mm. OCT can aid subsequent management. Alfonso et al.5 found that OCT readily identified the double-lumen morphologic characteristic of SCAD, the entry tear, the circumferential and longitudinal extent of the tear, side branch involvement, compromise of the true lumen, and distribution of the false lumen. OCT was particularly helpful when there was suspicion of intramural hematoma. Using OCT to guide BVS implantation in SCAD is important because it helps guide scaffold sizing in a vessel that is smaller than its reference size in the absence of normal flow, as well as detailing lesion characteristics. This is important when using BVS because lesion preparation is key to adequate scaffold expansion (> 0.5 mm above scaffold size after dilation is contraindicated because of the risk of scaffold fracture). Management of SCAD can range from conservative medical therapy to PCI and rarely coronary artery bypass grafting. It should be tailored to the individual case according to both clinical features and angiographic features.1-3 Conservative therapy may suffice when the patient is asymptomatic, the dissection involves small or distal vessels, or
1461.e3
when coronary flow is preserved.2 Antiplatelet agents, b-blockers, and vasodilators are the mainstay of medical therapy.2 PCI is appropriate in the presence of ongoing refractory or recurrent ischemia, or hemodynamic instability. If PCI is undertaken, there must be careful consideration of scaffold expansion and length to avoid propagation of the dissection into unaffected coronary segments.3 When there is left main multivessel involvement or concomitant valve disease, surgical revascularization may be preferable.3 There are a number of potential advantages to using BVS in SCAD. BVS offers both drug elution and temporary scaffolding of the vessel, with the theoretical advantage of restoration of native vessel biomechanical characteristics (vessel vasomotion/adaptive shear stress/late luminal enlargement/late expansive remodelling). Conclusions SCAD is an uncommon cause of acute coronary syndromes. OCT is a useful diagnostic tool that also aids treatment. BVS may offer an alternative to metallic stents when PCI is considered. Disclosures The authors have no conflicts to disclose. References 1. Saw J, Ricci D, Starovoytov A, et al. Spontaneous coronary artery dissection: prevalence of predisposing conditions including fibromuscular dysplasia in a tertiary center cohort. JACC Cardiovasc Interv 2013;6: 44-52. 2. Tweet MS, Hayes SN, Pitta SR, et al. Clinical features, management, and prognosis of spontaneous coronary artery dissection. Circulation 2012;126:579-88. 3. Vrints CJ. Spontaneous coronary artery dissection. Heart 2010;96:801-8. 4. Maehara A, Mintz GS, Castagna MT, et al. Intravascular ultrasound assessment of spontaneous coronary artery dissection. Am J Cardiol 2002;89:466-8. 5. 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.
Supplementary Material To access the supplementary material accompanying this article, visit the online version of the Canadian Journal of Cardiology at www.onlinecjc.ca and at http://dx.doi.org/10. 1016/j.cjca.2014.06.025.
