SCAD managed with a novel technique which avoids coronary stenting, an EHJ case report.

Spontaneous coronary artery dissection (SCAD) is a rare condition which is usually managed conservatively but when presenting as an acute coronary syndrome, interventionists are usually inclined towards stenting the involved segment. However, Unzue et al have devised a novel "pull-back" technique to manage SCAD and achieving optimal result without stenting the coronary artery. This case report was recently published in EHJ case reports.

A young man was admitted with acute chest pain and ST segment elevation in precordial v3–v6 leads. An emergent coronary angiogram showed an abrupt occlusion of middle left anterior descending artery compatible with SCAD.

Revascularization in the setting of SCAD remains controversial and technically challenging and is associated with high rates of technical failure, dissection extension, and failure to cross the lesion. Stent implant in this scenario has been associated with malposition, thrombosis, and events in the follow-up.

The authors advanced a BMW wire through the occlusion, without restore of distal flow. A Finecross microcatheter was then placed in distal LAD and pulled back with continuous contrast injection through the catheter (Figure), restoring the flow with a residual spiroid intimal flap and with relief of the chest discomfort.

Given the complete occlusion of the artery and the low-risk-bleeding of the patient, medical treatment with aspirin 100 mg/day, clopidogrel 75 mg/day, and 80 mg enoxaparin/12 h was maintained during admission performing a 320-sliced coronary computed tomography (CT) 1 week after the procedure to control the evolution of the artery in order to avoid the risk of a second coronary angiogram. The CT showed complete resolution of the intimal flap with restore of the distal flow and a residual image at the SCAD entry point.

Luminal obstruction in SCAD is caused by compression of the artery due to a haematoma placed within the vessel media or by dissection of the intima and not by atherosclerotic plaque, therefore the aim of the angioplasty should pursue the restoration of the distal flow by recovering the communication between the false and true lumens. Different strategies have been proposed in this scenario, with a stepwise algorithm that includes plain old balloon angioplasty and cutting balloon dilatation, trying to avoid the stent implantation in these patients.

The goal of the percutaneous intervention in SCAD should pursue the restoring of the distal flow, but not a 'perfect' angiographic result without residual stenosis. In this setting, some authors have proposed a change in the definition of 'success of the intervention' in the context of SCAD replacing the residual stenosis by a SCAD-specific definition established by improvement of the vessel flow.

The presented technique proposes an easy and non-aggressive way to restore the distal flow of the vessel, re-establishing the connection between false and true lumen by vigorous injection of contrast through a microcatheter placed in the distal vessel recovering the flow of the artery and allowing a complete healing during follow-up.

"In SCAD with complete occlusion of the vessel, the 'pull-back technique' with continuous vigorous injection of contrast through a distal microcatheter may be effective to restore the distal flow enabling the healing of the artery at follow-up and avoiding the stent implant", concluded the authors.

Source: EHJ case reports: https://doi.org/10.1093/ehjcr/ytab165