Author + information
- Pascal Motreff, MD, PhD,
- Thibault Ronchard, MD, PharmD∗ (, )
- Francesca Sanguineti, MD,
- Guy Achkouty, MD, MSc,
- Hakim Benamer, MD,
- Gregoire Range, MD,
- Thierry Lefevre, MD,
- Georgios Sideris, MD, PhD,
- Andréa Cianci, MD,
- Nicolas Combaret, MD and
- Géraud Souteyrand, MD
- ↵∗CHU de Clermont-Ferrand, Service de Cardiologie, Hôpital Gabriel Montpied, 58 rue Montalembert, 63003 Clermont-Ferrand, France
Spontaneous coronary artery dissection (SCAD) is an underdiagnosed clinical entity with a severe prognosis. Whereas conservative management is followed in asymptomatic patients with reassuring hemodynamic status and TIMI (Thrombolysis In Myocardial Infarction) flow grade 3 on angiography, high-risk SCAD with recurrent ischemia and/or hemodynamic instability necessitates revascularization (1). Because conventional percutaneous coronary intervention and surgical revascularization are technically difficult, and long-term outcomes are often suboptimal (2,3), fenestration may be a rescue option in cases of long and wide hematoma without intimal rupture. The intima is cut with a cutting or scoring balloon, allowing intramural hematoma decompression, restoring flow, and limiting the risk for hematoma progression or coronary occlusion by a large amount of clotting.
No systematic studies of fenestration have been reported. We performed a retrospective multicenter study of 71 patients (mean age 48 years, 89% women, 51% without additional risk factors, 35% presenting with ST-segment elevation myocardial infarction and 65% with non–ST-segment elevation myocardial infarction) with confirmed SCAD (clinical acute coronary syndrome with myocardial infarction and identified by coronary angiography and optical coherence tomographic imaging if necessary) among 6,323 cases of acute coronary syndrome recorded at 5 French cardiology centers between October 2014 and October 2017.
Conservative management was preferred, with percutaneous coronary intervention in cases of ongoing ischemia and/or hemodynamic instability. No patients were treated with coronary artery bypass grafting. Nine patients required urgent revascularization (4 stent implantations and 5 fenestration procedures). One of the patients initially treated by fenestration required a stent; 1 patient initially stented required a second stent, and 2 stented patients required fenestration. Six patients with initial conservative management required deferred percutaneous coronary intervention (4 fenestrations and 2 stent implantations). In all, fenestration was performed in 11 patients (see Figure 1).
Ten of the 11 patients treated with fenestration were women; the average age was 47 years. TIMI flow grade was 0 (n = 6), 2 (n = 3), and 3 (n = 2). All patients had intramural hematoma with luminal compression corresponding to defining features previously reported (4). Clinical instability was observed in 8 patients, and hematoma expansion was identified on angiography in 3 asymptomatic patients. Two patients initially presented with concomitant cardiogenic shock. The clinical presentation was ST-segment elevation myocardial infarction in 4 cases and non–ST-segment elevation myocardial infarction in 7 cases.
Eight patients were treated with scoring balloon (AngioSculpt, Spectranetics, Colorado Springs, Colorado) and 3 patients with cutting balloon (Flextome, Boston Scientific, Natick, Massachusetts) angioplasty. The balloon diameter was the same as or 0.5 mm smaller than the artery. The balloon was inflated at nominal pressure 3.5 times on average, for an average cutting length of 74 mm. The hematoma was incised over its entire length or at reduced length, at the operator’s discretion. Nine patients received a stent to stabilize the dissection induced by the fenestration. Post-procedure, 9 patients received dual-antiplatelet therapy; 1 patient who was not stented received aspirin alone.
The procedure was successful, defined as confirmed lack of hematoma expansion after angioplasty and TIMI flow grade 3 without pericardial effusion, in all patients. One patient died during hospitalization (brain death, secondary to initial cardiac arrest) despite recovery of TIMI flow grade 3, electrocardiographic normalization, and stabilization of hemodynamic status. In 1 patient, the dissection was not stented in its most proximal part after fenestration, as the restoration of TIMI flow grade 3 and disappearance of symptoms indicated good chances for spontaneous healing. After 4 days, the patient presented with non–ST-segment elevation myocardial infarction recurrence and progression of proximal dissection requiring new stenting. The patient was asymptomatic at 1 month with a normal left ventricular ejection fraction. We recommend stabilizing the dissection in its proximal part. The other patients stabilized and did not require further intervention.
All 10 surviving patients have maintained freedom from symptoms and good cardiac function on transthoracic echocardiography over 1- to 36-month follow-up at the time of writing.
To our knowledge, this study represents the largest set of patients with SCAD treated with fenestration to date for whom procedural success rates and long-term follow-up data have been obtained. In all 11 patients, flow was restored using scoring or cutting balloon angioplasty with favorable long-term results. The greatest limitation of the analysis is the heterogeneity of the cohort, with wide variations in, for example, time of fenestration, TIMI flow grade at baseline, use of control angiography, and follow-up duration. Although indications for fenestration are rare, as SCAD occurs in young patients, it merits greater awareness among physicians. The optimal incision length is still uncertain and should be evaluated in controlled studies in larger numbers of patients.
Please note: Drs. Motreff and Souteyrand are consultants for Abbott/St. Jude Medical. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- 2018 American College of Cardiology Foundation
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