Author + information
- Received December 13, 2011
- Revision received January 11, 2012
- Accepted January 20, 2012
- Published online April 1, 2012.
- Fernando Alfonso, MD⁎ (, )
- Manuel Paulo, MD and
- Jaime Dutary, MD
- ↵⁎Reprint requests and correspondence:
Dr. Fernando Alfonso, Interventional Cardiology, Cardiac Department, Cardiovascular Institute, Hospital Universitario Clínico San Carlos, Ciudad Universitaria, IdISSC, Plaza de Cristo Rey, 28040 Madrid, Spain
Spontaneous coronary artery dissection (SCD) is a rare clinical entity (1,2). Clinical diagnosis is challenging and classically relies on the angiographic demonstration of an intimomedial “flap” leading to a double lumen appearance (1,2). Angiography, however, is unable to visualize the coronary wall. New intracoronary diagnostic tools provide comprehensive, tomographic, high-resolution insights on vessel wall pathology, allowing a precise diagnosis of SCD (3,4).
A 58-year-old woman presented with a non–ST-segment elevation inferior myocardial infarction. Angiography (Fig. 1A) revealed a normal right coronary artery with just minor lumen irregularities. Intravascular ultrasound (IVUS) (Fig. 1B) (resolution: 150 μm) disclosed a large intramural hematoma along the entire right coronary artery. The coronary lumen was fully preserved, the coronary wall was readily recognized, and the abluminal hematoma (asterisks) had a heterogeneous pattern suggesting recent bleeding and ongoing thrombus formation. Optical coherence tomography (OCT) (Fig. 1C) (resolution: 15 μm) identified a confined proximal entry tear (arrow) leading to a large distal intramural hematoma (Fig. 1D). The clinical course was uneventful with conservative medical management.
Intravascular diagnostic techniques provide novel insights into the pathophysiology of SCD (3,4). Currently, many patients with negative angiographic findings are readily diagnosed with these tools if the level of clinical suspicion is adequate. The present case clearly illustrates their potential complementary value in selected patients. OCT provides uniquely high-resolution images of the intimomedial “flap” and is able to accurately identify the “entry door.” However, most of the outer boundary of the vessel is not visualized (especially in large vessels), and the presence of red thrombus (or thrombin-rich intramural hematoma) produces dorsal shadowing, preventing visualization of posterior structures in the coronary wall. Alternatively, IVUS has a lower axial resolution but better depicts the complete vessel wall, even in patients with intraluminal red thrombus and in those with large coronary vessels.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received December 13, 2011.
- Revision received January 11, 2012.
- Accepted January 20, 2012.
- American College of Cardiology Foundation