46-year-old female, active smoker, over the past two days experienced chest pain accompanied by cold sweats. At addmission TA 80/60mmHg. Cardiac and pulmonary findings appear to be within normal parameters.
ECG at admission:
ECHO shows akinesis of all apical segments.
Coronarography was performed:
On call interventional cardiologist failed to recognize SCAD
PCI LAD:
Loss of flow distally after stent placement; on-call doctor ends the procedure.
ECG after cath lab
Despite ongoing maximal drug therapy, the patient continues to experience symptoms with persistent ST elevation on the ECG.
Coronarography after 12h:
An intimal flap is observed at the distal edge of the stent, potential proximal propagation and the distal occlusion.
IVUS:
Confirmed SCAD type IIb/IV
Further continuation of drug therapy: ASA 100 mg, Clopidogrel 75 mg, Pantoprazol 40 mg, Atorvastatin 40 mg, Bisoprolol 2,5 mg
Follow up 3 months
Coronarography:
The patient exhibits TIMI III flow with a residual intimal flap in the distal segment, yet remains asymptomatic without any new symptoms.
ECHO:
Based on what would you conclude that it is SCAD?
How would you perform the procedure if you have identified SCAD?
1. In all young female (under 50 years of age) pts with confirmed ACS, SCAD should ALWAYS be assessed as a possible cause.
2. Based on diagnostic cranial projection, there was a high suspicion of SCAD
3. Addition cranial projection with left angulation (haemiax) could further clarify anatomy, and possible spontaneous dissection.
4. I could not see any low pressure predilatation with small semi compliant balloon to restore flow (that would be my very first move after placement of the wire into the distal true lumen).
5. The first stent (if needed) should be always placed over the bifurcation with a big septal, at least 3-4 mm (5 is a optimum) to avoid any plaque or intramural hematoma shift towards proximal LAD.
6. The “dissection” at the distal edge after the first stent is probably propagation of the intramural hematoma and further compression of the LAD (it is possible to be a dissection flap in case that wire was placed into subintimal space or real stent distal edge dissection)
7. Please, consider these comments as a friendly discussion, as it is always easy to a general after the battle.
Many thanks to UCC Nis for posting this intriguing SCAD cae. Agree with professor Stojkovic that the age of the patient and no visualisation of the coronary atherosclerotic disease on other arteries, should raise suspicions on SCAD. And that it is just the beginning of controversial road of how to properly treat this condition. In a particular case (ST elevation, chest pain, hemodynamic instability), the flow in the LAD should be restored and a cutting baloon might be a good option for the opening (LAD and our vision). However, follow up result is extremely good and after we overcame two major obstacles (first – think of SCAD, second – decide quickly how to treat it), we face the final: what was the cause and how this SCAD patient should behave: to exercise or not, to get excited or not etc
Very interesting case. This case is confirms how is important continuous education in this field. Always we must to think about SCAD in everyday work in cath lab. ” SCAD patient model” young patent, especially women, without traditional risk factors for CAD.