coronary artery dissection

1. Coronary artery dissection

2. epidemiology
• Spontaneous coronary artery dissection is the cause of acute
coronary syndrome in o.1 to 4 % of cases
• SCAD has been reported to account for nearly a quarter of cases of
ACS women < 50 years old
• Classically though it affects young women , SCAD now increasingly
recognized to also occur in older and post menopausal women
• Men also present with SCAD ( <10 to 15 % of cases however , these
are more likely atherosclerotic in origin than non atherosclerotic

3. • Spontaneous coronary artery dissection
- Non atherosclerotic SCAD
- Atherosclerotic SCAD

4. SCAD
• A non traumatic and non iatrogenic separation of the coronary
arterial wall
• A rare cause of acute MI
• It is more common in younger patients and women

5. Pathogenesis
• An intimal tear or bleeding of vasovasorum with intra-medial
haemorrhage
• It result in the creation of a false lumen filled with intramural
haematoma
• Pressure driven expansion of the false lumen filled with intramural
haematoma may lead to luminal attachment and subsequent MI
• Or it can result in extensive dissection lengths, especially in the
presence of arterial fragility from predisposing arteriopathies

6. • In pregnant or early postpartum women, dissection may be a
consequence of increased physiological haemodynamic stresses or
from harmonal effects or from harmonal effects weakening the
coronary arterial wall.
• Intramural haematoma involving the outer two of the media is
common.

7. Conditions associated
• Postpartum status
• Fibromuscular dysplasia
• Multiparity ( >4 births)
• Connective tissue disorders
• Harmonal therapy

8. Clinical manifestations
• Patients with non atherosclerotic spontaneous coronary artery dissection (
NA- SCAD) usually present with symptoms and signs characteristic of acute
MI
• Chest pain
• Arm pain
• Neck pain
• Nausea or vomiting
• Diaphoresis
• Dyspnea and back pain
• Life threatening ventricular arrthmias occurs in 4 to 14 %

9. Findings in CAG
• The LAD was the most frequently affected vessel ( 40 to 70%)
• The most commonly observed angiographic was type 2 ( 67%)

10. diagnosis
• Criteria for the angiographic definition include the presence of Non
iatrogenic dissection plane in the absence of coronary atherosclerosis,
with typical changes of radiolucent intimal flap and contrast straining
stereotypical changes were seen only in <30% of Non atherosclerotic
SCAD
• The majority of NA SCAD had long and diffuse narrowing on
angiography due to intramural haematoma, and this appearance was
frequently unrecognised on CAG leading to under diagnosis of this
condition

11. ANGIOGRAPHIC CLASSIFICATION
• Type 1: Pathognomonic contrast dye staining of arterial wall with
multiple radiolucent lumen, with or without dye hang up or slow
contrast clearing
• Type 2: Diffuse long and smooth stenosis that can vary in severity
from mild stenosis to complete occlusion
• Type 3 : Mimics atherosclerosis with focal or tubular stenosis and
requiring OCT or IVUS to differenciate the cause

12. TYPE1

13. TYPE 2

14. TYPE 3

16. Management
• Conservative therapy is preferred strategy after the diagnosis is
secured.
• Patients presenting with acute MI who have symptoms of ongoing
ischemia or haemodynamic compromise should be considered for
revascularization with PCI or CABG
• Many Patients have been managed with long term aspirin, beta
blocker and 1 year clopidogrel with addition of a ststin in patients
with dyslipidemia

17. ATHEROSCLEROTIC SCAD
• is a mechanistically distinct variant of SCAD and is typically limited in
extent by medial atrophy and scarring

18. • Dissections result from overly vigorous attempts at guidewire
passage, but most are due to the controlled injury induced by
inflation of the dilation catheter
• The occurrence of dissection cannot be predicted by preintervention
analysis of lesion morphology or plaque composition of intracoronary
ultrasound (IVUS).

20. • The increased risk of abrupt closure and MI associated with alarge
dissection has led to the routine use of stenting for any dissection
• Most cases of acute closure occur within minutes of final balloon
inflation, but subacute closure occurs upto hours later 0.5 to 1 % of
cases typically as the heparin anticoagulation weans off
• Stents reverse abrupt closure in more than 90% of cases . However
some patients still require bypass surgery after stenting because of
persistent coronary occlusion or dissection resulting in ischemia

22. Thank you