Article, Cardiology

Spontaneous coronary artery dissection and pseudoaneurysm: a case report

Spontaneous coronary artery dissection a”>Case Report

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American Journal of Emergency Medicine

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Spontaneous coronary artery dissection and pseudoaneurysm: a case report

Abstract

Spontaneous coronary artery dissection (SCAD) is a very rare but potentially fatal condition, which often causes acute myocardial infarction and sudden cardiac death. Spontaneous coronary artery dissection associated with pseudoaneurysm has been rarely reported mostly managed with Coronary artery bypass grafting. We report a female patient with SCAD and pseudoaneurysm who was treated by successful percutaneous coronary intervention.

A 26-year-old woman presented to the emergency department of a district hospital with chest pain. Her electrocardiogram (ECG) showed sinus rhythm and T-wave inversion in leads V1 to V6 with a troponin level of 11.7 ng/mL. She was diagnosed with non-ST-segment elevation acute myocardial infarction. The patient was given clopidogrel, aspirin, and atorvastatin. Twenty days later, she presented to our hospital with stable vital signs. She had no history of hypertension, diabetes, hyperlipidemia, smoking, or family history of premature cardiovascular disease. She was on oral contraceptives for half a year and had a previous history of vitiligo. She was gravida 1 and para 1 and delivered 3 years ago. There were a 1 x 0.8 cm white spot under the armpit and a 1 x 1 cm white spot on the right side of the abdomen. Electrocardiogram had no significant change when compared with previous ECG. The patient’s troponin level was 0.04 ng/mL, and the levels of total cholesterol, low- density lipoprotein cholesterol, and cardiac enzymes were normal. Antinuclear antibody, anti-ds-DNA, and extractable nuclear antigen polypeptide were all negative. Echocardiography showed no significant abnormality. Selective coronary angiography, which was performed 2 days later, revealed proximal left anterior descending artery (LAD) dissection and pseudoaneurysm that compresses the left main coronary artery (Fig. 1). Intravenous ultrasound confirmed the dissection and the pseudoaneurysm (Fig. 2). Conservative management was chosen due to complexity of the procedure. Antiplatelet therapy was stopped, and the patient was kept on metaprolol and enalapril. The patients’ heart rate was controlled at 60 to 70 beats per minute, and her blood pressure was 85 to 90/55 to 60 mm Hg. The probable Management strategy for this patient was Pharmacological management, percutaneous coronary intervention (PCI), or coronary artery bypass surgery. Taking into account the pseudoaneurysm compressing the left main coronary artery, we considered that the risk of coronary rupture and Pericardial tamponade was very high. Because the patient was very young, she did not accept coronary artery bypass grafting (CABG). We decided to perform PCI. Eight days later after the first coronary angiography, another coronary angiogram was performed. We found that the coronary artery pseudoaneurysm extended (Fig. 3). We decided to implant stents in the LAD and the left main coronary artery. Firstly, cutting balloon was dilated from the ostium of the anterior descending branch to the left main coronary artery, which was followed by implantation of 2 stents with postdilatation (Fig. 4). The patient did not

complain of discomfort in the process; ECG was no obvious change than before. After the procedure, the patient was on aspirin and clopidogrel. After 3 months of follow-up, the patient complained no discomfort.

Spontaneous coronary artery dissection (SCAD) is defined as a separation of the coronary arterial wall by hemorrhage, with or without an associated intimal tear [1]. Spontaneous coronary artery dissection is a very rare but potentially fatal condition, which often causes Sudden Cardiac Death and acute myocardial infarction. The first autopsy report involved a 42-year-old woman with SCD in 1931 [2]. Although no direct causes and no clear pathologic mechanisms have been identified yet, several conditions have been associated with SCAD, such as atherosclerosis, connective tissue disorders, and the peripartum period. According to the associated predisposing condition, SCAD has been broadly divided into athero- sclerotic and nonatherosclerotic. Spontaneous coronary artery dis- section is often described in young women, especially in the peripartum period. Other associations of SCAD described in the literature are connective tissue disorder, oral contraceptive use, Antiphospholipid syndrome, cocaine use, and fibromuscular dysplasia. The pathophysiology of SCAD is still not very clear. There are 2 proposed mechanisms of SCAD. First, an intimal rupture with subsequent disruption of the vessel wall leading to a double lumen. Second, bleeding of the vasa vasorum may result in an intramural

Fig. 1. The coronary angiography revealed proximal LAD dissection and pseudoaneur- ysm, which compresses the left main coronary artery.

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Fig. 2. IVUS confirmed the dissection and the pseudoaneurysm.

hematoma. Early diagnosis is very important to manage SCAD patients because it might preempt use of unnecessary and potentially harmful pharmacologic therapies, such as thrombolytic therapy. Spontaneous coronary artery dissection is a rare disease, and association with pseudoaneurysm is seldom reported [3]. We only found 5 cases that were reported in the literature. There is no consensus on the best treatment of SCAD. The most commonly used methods in the management of SCAD include conservative treatment, interventional therapy, and CABG. The therapeutic strategy is generally determined by the clinical condition and image findings. In most cases, conservative treatment is preferred for stable patients without active ischemia. Thrombolytic therapy in SCAD is not recommended for it can extend the dissection, which will result in poor prognosis. Percutane- ous coronary intervention is recommended in patients with ongoing chest pain, hemodynamic instability, ST elevation, or ischemia, especially when the dissection affects major arteries. Patients with dissected left main or proximal segments of LAD, circumflex, or right

Fig. 3. The coronary angiography revealed the coronary artery pseudoaneurysm extended.

Fig. 4. The coronary angiography revealed no residual stenosis in the anterior descending branch after we implanted 2 stents.

coronary artery should be intervened percutaneously if possible. Emergency CABG can be considered in cases of dissection of left main coronary artery or multivessel involvement. Recent literature reported that a “conservative” therapeutic strategy provides excellent long-term prognosis [4]. However, the condition of each patient is not consistent. In this case, coronary angiography showed fast progressing pseudoa- neurysm, which if not timely intervened, coronary perforation is likely to happen and the patient may suffer SCD. Most of patients with SCAD of the left main coronary artery or combined with the pseudoaneurysm were treated by CABG. However, CABG is much more traumatic than PCI. In this patient, the patient was treated by PCI and recovered quickly. In some cases with SCAD of the left main coronary artery or combined with the pseudoaneurysm, PCI may be a good choice. In conclusion, the decision should be combined with the specific circumstances of the patient.

Appendix A. Supplementary data

Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.ajem.2013.09.023.

Jun-Gang Nie MD Jian-Zeng Dong MD

Department of Cardiology, Beijing Anzhen Hospital Capital Medical University, Beijing 100029, China E-mail address: [email protected]

http://dx.doi.org/10.1016/j.ajem.2013.09.023

References

  1. Saw J. Spontaneous coronary artery dissection. Can J Cardiol 2013;9:1027-33.
  2. Pretty H. Dissecting aneurysm of coronary artery in a women aged 42. BMJ 1931:667.
  3. Furuichi S, Montorfano M, Godino C, et al. How should I treat a long and huge coronary pseudoaneurysm after spontaneous coronary artery dissection? Euro- Intervention 2011;6:1131-6.
  4. Alfonso F, Paulo M, Lennie V, et al. Spontaneous coronary artery dissection: long- term follow-up of a large series of patients prospectively managed with a “conservative” therapeutic strategy. JACC Cardiovasc Interv 2012;10:1062-70.

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