coronary artery dissection: a comparison of different entities

Citation: Dr. M. Adnan Raufi. “Coronary Artery Dissection: A comparison of different entities” MAR Cardiology 3.3 www.medicalandresearch.com (pg. 1)

Research Article Journal of MAR Cardiology (Volume 3 Issue 3)

Coronary Artery Dissection: A comparison of different entities

M. Adnan Raufi*1, Evan Shlofmitz3, Khady Fall4, Yasir Parviz2.

1*. Belhoul Speciality Hospital, Dubai, UAE

2. Canadian Specialist Hospital. Dubai. UAE

3. MedStar Washington Hospital Center, Washington, D.C., USA

4. New York-Presbyterian Hospital/Columbia University Medical Center, New York, NY, USA.

Corresponding Author: Dr. M. Adnan Raufi, Belhoul Speciality Hospital, Dubai, UAE

[email protected]

Copy Right: © 2021 M. Adnan Raufi, this is an open access article distributed under the Creative Commons

Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the

original work is properly cited.

Received Date: August 25, 2021

Published date: September 01, 2021

Abstract

Coronary artery dissection is one of the challenging situations routinely faced by clinicians in the cardiac catheterization laboratory. Although underappreciated by angiography alone, dissections occur frequently with intervention and are of varied clinical significance.

The dilemma is in the correct diagnosis and appropriate decision making to ensure an optimal clinical outcome. Coronary artery dissection can be spontaneous (Spontaneous Coronary Artery Dissection, SCAD), secondary to the rupture of an atherosclerotic plaque or iatrogenic (as a result of the interventional procedure). This article presents an overview of the definition, classification, etiology, clinical manifestations, and potential complications associated with coronary artery dissections. An incomplete assessment of the clinical significance of coronary dissections can be associated with suboptimal outcomes. We present a comparative overview of accurate and comprehensive assessment and management strategies for different coronary dissections.

Key Words: Dissection, Spontaneous Coronary Artery Dissection (SCAD), Intravascular ultrasound (IVUS), Optical Coherence Tomography (OCT).

http://www.medicalandresearch.com/

mailto:[email protected]

Journal of MAR Cardiology (Volume 3 Issue 3)

Citation: Dr. : Dr. M. Adnan Raufi. “Coronary Artery Dissection: A comparison of different entities” MAR Cardiology 3.3

www.medicalandresearch.com (pg. 2)

INTRODUCTION

Coronary artery dissection is a condition when a tear occurs in any of the three layers of the arterial

wall and in its most severe form, blood can pass through the innermost layer and becomes trapped

and bulges inward. This eventually causes narrowing in the lumen of the artery and can lead to a

compromise in the blood flow to the myocardium.

Although angiography is routinely performed and considered a gold standard for diagnosis of CAD, [1,

2], coronary artery dissection can be a challenge to diagnose and manage solely based on angiography.

[1, 2]

In this article, we provide an overview of how to comprehensively assess a coronary dissection and how

best to make a treatment decision by using adjunctive modalities. [3, 4]. Despite the potentially

harmful implications of visual estimation techniques, it remains the most commonly used form of

evaluation for coronary lesions as well as the coronary artery dissections and is still widely practiced

[5]. The limitations of angiography are evident with regards to assessment and decision making for the

management of coronary artery dissections.

The differentiation between various etiologies and severity of dissection is important, as the treatment

strategies are different in various clinical settings. [Table].

Table





Coronary artery dissection has been categorized from type A to F in the NHLBI classification with risk

of vessel closure increases with the complexity of dissection from type A to F as shown in figure

1below.

Figure 1

Plaque Rupture as a Cause of Coronary Artery Dissection:

Pathophysiology:

Plaque rupture, usually of a precursor lesion known as a 'vulnerable plaque' or 'thin-cap fibro

atheroma' (TCFA), is the leading cause of thrombosis and can present as a dissection on the

angiogram.

A CASE OF PLAQUE RUPTURE CAUSING DISSECTION:

A male patient with a history of hypertension, diabetes mellitus, and hyperlipidemia presented with

NSTEMI-ACS. His echocardiogram showed mild left ventricular systolic dysfunction. His cardiac

catheterization showed no significant stenosis in the left coronary system, however, a dissection flap

was found in a large caliber, dominant right coronary artery. Angiogram image is shown below in

Figure 2.

Figure 2: A dissection flap (arrow) in a large caliber, dominant right coronary artery.





An IVUS was also performed which revealed a ruptured plaque and was responsible for the acute

presentation of the patient. [Figure 3].

[Figure 3]: IVUS showing a dissection flap (arrow)

The lesion was successfully treated with a Self-apposing stent, which resulted in complete sealing of

the plaque and dissection flap. [Figure 4 a,b. Below].

Figure 4a





Figure 4b

FACTORS ASSOCIATED WITH PLAQUE RUPTURE:

A variety of factors have been attributed to the mechanisms leading to plaque rupture and the

appearance of dissection on the angiogram.

These include increased shear stress injury,[6] turbulent plaque injury,[7] transient collapse of the

stenosis,[8] rupture ofvasa vasorum,[9] and circumferential stress within the plaque.[10]

Contemporary literature supports that an inflammatory process plays a crucial role in the mechanism

of plaque rupture.[11]

IATROGENIC DISSECTION

ETIOLOGY:

Iatrogenic dissection occurs during a coronary angiogram or percutaneous coronary intervention.

Normally this is hardware induced and could be due to catheter, wire, balloon, or stents or various

other adjunctive equipment used during coronary interventions including guide extension catheters,

imaging probes, ‘mother-and-child catheters, and atherectomy devices.

PATHOPHYSIOLOGY:

Guide catheters may induce dissections in the ostio-proximal segment of the vessel and may occur

with increased incidence with the use of guide extension catheters. These may occur when the guide

catheters are not coaxial to the vessel. Small aortic root dimensions and aggressive manipulations of

the catheters can increase the chances of these dissections. These dissections can extend proximally

into the aortic root or propagate down the coronary artery.





INCIDENCE:

Guide catheter induced dissection is common in the cases where there is ostial disease and aggressive,

large size, supportive guide catheters are used.[12] The exact incidence remains unknown, with some

suggesting it may be underreported. [13]

A CASE EXAMPLE OF IATROGENIC DISSECTION:

A young female patient presented with ongoing symptoms of chest pain and was evaluated by coronary

angiography. (Figure 5).

Figure 5: A case of catheter induced RCA dissection and complete occlusion of artery.

CLINICAL SIGNIFICANCE:

During balloon angioplasty, coronary dissection is inevitable and occurs nearly universally. This

however often is limited to small intimal dissections that are not evident angiographically and of no

clinical significance when covered with a stent. This has been recognized more recently with high-

resolution intravascular imaging such as optical coherence tomography. Increased sensitivity for the

detection of dissections with OCT has allowed for stratification based on severity to determine

management strategy.

Invasive physiologic assessment often involves coronary wires with reduced steerable dexterity and

there is a risk of dissection. For instance, in the ORBITA study 4% of patients undergoing physiologic

assessment that were randomized to undergo conservative management, crossed over to PCI due to

wire-related dissections.[14] Following stent implantation, edge dissections may frequently occur.[15]

The overall incidence of edge dissections following stent implantation as assessed by OCT has been

reported as 37.8%, with 84% not detectable by angiography.[16] There is a relationship between

plaque-type and risk for edge dissection. Edge dissections may be minimized when a stent edge is

implanted in normal or fibrous tissue and by avoiding implanting the edge of a stent within a region of

lipid plaque with TCFA.





PREVENTION:

During the engagement of guide catheters, extra care needs to be taken to ensure the coaxial

engagements and an operator should always monitor the arterial waveform to ensure that there is no

ventricularization or damping in the aortic pressure waveform. The tracing below is to show a case of

Coronary Ventricularization which was identified and corrected by careful catheter removal. (Courtesy

Dr. Raufi)

Dissection associated with a guide catheter can be asymptomatic but it can lead to disastrous

consequences and sometimes it necessitates urgent revascularization.

MANAGEMENT:

Coronary dissections caused by balloon angioplasty, intracoronary imaging probes, and other

equipment into the vessel can similarly have varied consequences. Stents can be used to easily seal

dissection flaps to prevent acute or abrupt vessel closure. If dissection involves the ostio-proximal

segment of a vessel close to the aortic root, adequate sealing of the ostium with an appropriately

expanded stent is important to minimize the risk of retrograde propagation. Small asymptomatic

dissections (types A and B) may settle conservatively.





The dissections related to balloons or stents may be seen at both ends of the device. The stent-related

edge dissection is a known phenomenon. Unless there is less than 20 degrees edge dissection on IVUS,

most of these edge dissections need to be treated by further stents as if untreated, may progress to the

reduction of flow.

The dissections related to wire almost unanimously related to the distal segments and may complicate

with perforations. If it happens, the diagnosis needs to be made immediately by echocardiogram. Due

to the small size of the segments, treatment may be challenging and if the severity has extended to a

coronary perforation, may require implantation of coils. From the precautionary standpoint, a

continuous check on the wire position while performing angioplasty is mandatory. This becomes more

important while maneuvering balloons or stents in complex anatomy, particularly in tortuous vessels.

SPONTANEOUS CORONARY ARTERY DISSECTION:

DEFINITION:

Spontaneous Coronary Artery Dissection (SCAD) is a non-traumatic and non-iatrogenic separation of

the coronary arterial walls, creating a false lumen [2, 17].

INCIDENCE:

SCAD has a possible incidence of up to 1% to 4% of acute coronary syndrome (ACS) cases. [18-20].

This incidence can be high particularly in the cases of pregnancy-associated myocardial infarction (MI)

[21-23].

PATHOPHYSIOLOGY:

The separation of the coronary arterial walls in SCAD can occur between the intima and media or

between the media and adventitia, with intramural hematoma (IMH) formation within the arterial wall

that compresses the arterial lumen, decreasing antegrade blood flow with subsequent myocardial

ischemia or infarction [2, 17]. The dissecting hematoma is located in the outer third of the tunica

media and produces luminal occlusion by forcing the inner media against the opposing wall. Blood

filling the false lumen may simulate a coronary thrombosis to the naked eye. Thus, the real incidence

of this entity may be underestimated at autopsy, unless a careful histologic examination of the

coronary artery is done. In comparison with aortic dissections, an intimal tear is difficult to observe in

spontaneous cases, suggesting that the source of blood may be through vasa vasorum bleeding.

Multivessel SCAD may occur in up to 23% of cases [18, 24, 25].





A variety of conditions have been observed to predispose the patients to SCAD and one of the

important considerations to note is that fibromuscular dysplasia (FMD) and extra-coronary vascular

abnormalities may be commonly found in patients with SCAD. [17, 18, 23, 26, 27]

Pregnancy and sex hormones are similarly associated with predisposition to SCAD [23, 28, 29]. In this

context, we present an example of a post-pregnancy patient who presented with acute coronary

syndrome; however, her cardiac catheterization revealed SCAD. (Figure 6).

Figure 6: An example of Spontaneous Coronary Artery Dissection post pregnancy presenting as Acute Coronary Syndrome

A case of widespread Spontaneous Coronary Artery Dissection is mentioned below.

Figure 7: A case of widespread Spontaneous Coronary Artery Dissection

Similarly, there is an association reported between SCAD and sarcoidosis (23,30). Genetic

predisposition has also been reported. [18, 23] The term SCAD is synonymous with non-

atherosclerotic SCAD to differentiate from the atherosclerotic SCAD due to its peculiar

pathophysiology features.[23] [33, 34].

ANGIOGRAPHIC AND OTHER IMAGING DIAGNOSIS OF SCAD:

Despite the inherent limitations of conventional coronary angiography that reduces the diagnostic

capability for coronary dissection, this is still the most common test performed for the diagnosis of





SCAD. The limiting factor is 2-dimensional “luminography” making the operator not fully able to image

the arterial wall.

Advances in interventional cardiology and particular intracoronary imaging modalities including

intravascular ultrasonography and optical coherence tomography, provide detailed visualization of the

arterial wall that aids the diagnosis of various types of coronary dissection. Furthermore, intravascular

imaging goes beyond simple diagnosis and provides detailed information on the severity that can be

deterministic of the treatment approach. Despite the advantages of intracoronary imaging, there are

limitations due to additional risks of propagating the dissection, costs, expertise in interpretation and

they are not readily available in all catheterization laboratories worldwide. As a consequence,

conventional coronary angiography remains instrumental in diagnosing coronary artery dissections

and in particular the SCAD, and cardiologists should become proficient at recognizing its various

angiographic patterns. The pathognomonic appearance of SCAD as a radiolucent lumen with

extraluminal contrast staining is not seen in all cases.

Several studies have reported that the diffuse smooth stenosis pattern (i.e., type 2) is the most

common angiographic manifestation of SCAD, occurring in up to 67.0% of dissected arteries, followed

by type 1 in 29.1% and type 3 in 3.9%.[31]

Thus, reliance solely on the traditional multiple lumens or contrast staining of arterial walls to

diagnose SCAD might result in missing a diagnosis in more than 70% of SCAD cases. Therefore,

familiarity with the diffuse narrowed-lumen appearance of IMH and the use of intracoronary imaging

are important steps to improve the diagnosis of SCAD. An association of SCAD with Takotsubo

syndrome has been reported in literature. [26, 32, 33]

VARIOUS PATTERNS OF SCAD:

Three different patterns of SCAD have been characterized in the literature. [26]

(I) Type 1 is a condition where an obvious arterial wall strain is seen on angiography. This was

considered as pathognomonic in the SCAD series where multiple radiolucent staining of the arterial

wall is seen.

(II) Type 2 depicts a condition where diffuse stenosis of varying severity is seen.

This appearance can be misleading and can get confused with normal coronary stenosis.

SCAD can involve the mid to distal segments and can be so extensive that it can involve the entire

coronary tree





(III) Type 3 can present as atherosclerosis of the artery and can be very challenging to diagnose and

treat.

ANGIOGRAPHIC FEATURES FAVORING SCAD:

(i) Lack of atherosclerotic changes in other coronary arteries;

(ii) Long lesions (11-20 mm);

(iii) Hazy stenosis; and

(iv) Linear stenosis.

There are no apparent differences in clinical presentations among the three angiographic

classifications of SCAD. Type 1 SCAD should be easily diagnosed with angiography. Type 2 SCAD can

be distinctive enough for diagnosis by angiography due to the familiar classic pattern. However, some

type 2 cases (e.g., shorter lengths 20-30 mm) will require intracoronary imaging or repeat angiography

to make the diagnosis. Type 3 SCAD is often indistinguishable from atheroma and requires

intracoronary imaging for diagnosis.

ROLE OF INTRACORONARY IMAGING IN DIAGNOSIS OF VARIOUS TYPES OF DISSECTIONS:

The utility of intracoronary imaging has greatly helped us in the detailed understanding of various

dissections and strategies for the best management of these conditions.[34]

In this regard, IVUS has a very high penetration power and can be used for the differentiation of

various dissections.[35] One of the advantages of using IVUS is not using contrast material which may

be helpful in preventing the propagation and extension of dissection.[36] Due to the higher penetration

power of IVUS, the extent of the dissection process may be studied better. However, due to the low

resolution of IVUS systems, IVUS can help to differentiate between the false and true lumen and can

help localize the intimal tear. (Figure 8)

Figure 8: IVUS showing dissection flap of an ostial LAD. (A) Ostial LAD, (B) Ostial LCx, (C) Dissection with Flap,

(D) Left Main.





In clinical settings whenever there is suspicion of dissection on angiography, IVUS can be used to

locate the false lumen and it can help facilitate directing the wire into the true lumen. IVUS is superior

in many cases of dissection including left main stem (LMS) dissection.[35] [1] In these cases, IVUS

does not require the use of contrast and it avoids the hydraulic extension of dissection to other arterial

trees.[36]

IVUS can give detailed information about the dissected plaques [37]. (Figure 9)

(Figure 9) Intramural Hematoma, compression of the lumen by the echogenic hematoma. Lumen (E). Branch (F)

In the cases involving the LMS dissection, IVUS can help to locate the external elastic lamina (EEL)

due to high penetration in comparison to other imaging modalities including OCT. [1]

Large- scale registry data have shown that there is an advantage of OCT in detailed coronary artery

imaging and it can be utilized for assessment for the plaque. [37, 38]

OCT however uses a contrast medium to create a bloodless field and hence can cause hydraulic

extension of a dissection. This restricts its potential usage when a large dissection is apparent

angiographically despite having excellent imaging resolution.

There is not much information about the role of physiological assessment to help in the decision-

making process.

It may be deduced from the literature to have a low threshold of suspicion regarding the presence of

dissection and appropriate timing of treatment needs to be decided accordingly. Besides, an

appropriate imaging modality, if available, may help in decision-making [34]. An example of use of

OCT is mentioned below in Figure 10.





(Figure 10): Various images of coronary dissection as seen on OCT. The high resolution allows for clear identification of the

dissection flap.

MANAGEMENT OF SCAD:

The management of SCAD is dependent on the early and prompt diagnosis.

Medical therapy:

The medical management is considered on scenarios where the patient is clinically stable or in cases

where revascularization is not feasible.

There is no clear evidence that traditional medical therapies used in the treatment of ACS have any

beneficial impact. Aspirin and clopidogrel have been used for the treatment of SCAD. [34] There is no

clear evidence for use of potent P2Y12 antagonists (prasugrel and ticagrelor) for the treatment of

SCAD. Anticoagulant agents, like heparin are usually discontinued after confirmed diagnosis of SCAD

to avoid the extension of IMH. Beta-blockers have shown evidence to reduce arterial shear stress

and can potentially be used in cases of SCAD.[33] The role of ACE inhibitors and statins is not clear.

Revascularization Therapy:

The decision to revascularize in cases of SCAD can be very challenging and it depends on the patient’s

clinical status, affected coronary anatomy, and area of myocardium at risk.[23]

In those cases where the patient is stable without ongoing pain, it is reasonable to continue with

conservative management and in-patient monitoring.





The decision of revasculariztion is based on patient’s overall condition of ischemic chest pain and

hemodynamic instability in which case revascularization strategy is recommended provided major

arteries are affected and the technical feasibility is available [23][34]. This concept is explained in the

Algorithm below.

ALGORITHM

PCI in these cases may be challenging and the long-term outcomes are often not good. [23] The wiring

in these dissected arteries can be a challenge in order to navigate into distal true lumen. The IMH of

the dissected segment can also propagate antegradely or retrogradely during the procedure and

making the situation worse.





Thus, it is recommended that PCI to be considered for patients with ongoing chest pain and ischemia

when the lesion is amenable to stenting, and to consider CABG for extensive dissections involving the

left main.[23]

Conclusion:

In this review article, we have discussed coronary artery dissection, its etiology, and various types.

Several images outlining the various types of dissection are also mentioned. The algorithm mentioned,

provides a step-by-step approach for the reader to understand the pathophysiology and treatment of

the underlying disorder. A lack of case series without a follow up may pose a limitation to our

manuscript but it is beyond the scope of this article.

References:

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