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
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.
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
The patient exhibits TIMI III flow with a residual intimal flap in the distal segment, yet remains asymptomatic without any new symptoms.
Based on what would you conclude that it is SCAD?
How would you perform the procedure if you have identified SCAD?