A 48-year-old male presented with a history of chest pain during exertion over the past ten days. On admission, he experienced severe chest pain, rated at 9 out of 10 in intensity.
He has no known comorbidities, does not smoke, and has no family history of coronary artery disease (CAD).
Initial EKG revealed significant abnormalities, including ST depression in leads V1 to V5 and negative T waves in leads D1 and aVL
Transthoracic EHO on admission: globular left ventricle, hypokinesis of the inferolateral wall. Mitral regurgitation 2+
Given the severity of his symptoms and the EKG findings, an urgent referral to the catheterization lab was made.
Coronary angiogram:
A medial occlusion of the left circumflex (LCx) artery was discovered.
Notably, the left anterior descending (LAD) and right coronary artery (RCA) were free of disease.
Immediate percutaneous coronary intervention was performed.
Predilatation was performed using a 2.5x15mm semi-compliant balloon
Subsequently, a 4.5x16mm drug-eluting stent was successfully implanted at the site of the occlusion
However, post-stent implantation, it was observed that the occlusion appeared to have shifted distally.
This posed a new challenge, raising several critical questions about the next steps in the patient’s treatment.
To gain a better understanding of the situation, intravascular ultrasound (IVUS) was performed.
IVUS revealed the presence of an intramural hematoma, which explained the distal shift of the occlusion.
A decision was made to implant a second stent and a 4.0x20mm DES was placed successfully
Although the hematoma shifted distally once again, blood flow was preserved.
The patient remained stable throughout the procedure and during the post-operative period
He was discharged with the following therapy:
Dual Antiplatelet Therapy (DAPT)
High-intensity statin
Bisoprolol
Ezetimibe
Proton Pump Inhibitor (PPI)
Author: Dr Željko Živanović i Doc. Dr Bojan Stanetić
What did happen at this procedure?
Thanks for this case:
It is rare that the patient is a man (in this case younger men with ACS during exercise)
Type IV SCAD (arterial occlusion) is the most difficult to recognize, but it should certainly be considered
When, after the first stent, the dissection spreads, there is a high probability that it is SCAD, and then we think about the sandwich technique to stenting culprit lesion (if a flow is not TIMI 3). Good flow was the reason to stop procedure, I believe.
It will be interesting to see control coronarography!
Dear,
Very good case report. I agree with colleague I, in SCAD case with intramural hematoma, we must perform sandwich technic: first stent is always proximal of lesion, minimum 10 mm overlap stent in normal part of artery, 2nd. stent in distal part, again 10mm overlap in normal part of artery. In this case we trapped hematoma between two stents. 3nd stent we positioning in middle, between 1th and 2nd stent with standard overlap. After 1-2 months recommended to perform control coronarography with stent post dilatation if is necessary. In this period we have complete resolution of intramural hematoma and now patient have free space between stents and wall of artery.
Very interesting case, thanks for sharing.
Type 4 dissection is certainly the most difficult to recognize. After predilatation there were no signs of dissection. After stent implantation, a clear distal dissection is visualized. It is difficult to say whether there was a propagation of the hematoma originating from the SCAD or distal edge dissection propagation. I agree that it was the right moment to stop procedure, and perform recoronarography and OCT for 3 months.