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Although selective coronary angiography is the gold standard diagnostic technique for coronary lesions, this method does not provide all information regarding pathophysiologic mechanisms. We herein describe a patient in their early 60s with a 3-month history of pronounced angina. Coronary angiography revealed a central line of illumination in the proximomedial segment of the right coronary artery, suggesting a chronic coronary dissection/recanalized thrombus, along with positive remodeling and TIMI grade 2 flow. Optical coherence tomography showed a recanalized thrombus and multiple lumens separated by thin septa. Because of the significantly reduced flow and signs of ischemia in the right coronary artery irrigation territory, we decided to perform percutaneous coronary intervention. Post-treatment optical coherence tomography indicated optimal apposition and expansion of the stents with positive remodeling of the blood vessel. We believe that decisions regarding treatment modalities should be guided by the presence or absence of ischemia. Lesions that are causing myocardial ischemia should be revascularized; otherwise, medical treatment can be utilized.

IntroductionSCAD involves a sudden tear or separation within the layers of the coronary artery wall, resulting in blood flow obstruction and subsequent myocardial ischemia.Materials and methodsA comprehensive literature search was conducted to identify relevant published cases of cutting balloon use in patients diagnosed with spontaneous coronary artery dissection. Electronic databases including PubMed, MEDLINE, Embase, Cochrane Library and Google Scholar were systematically searched from inception until the present using terms “cutting balloon,” “SCAD,” “acute coronary syndrome,” “intramural hematoma,” and “angioplasty.”ResultsA total of 32 published cases of cutting balloon use in spontaneous coronary artery dissection were analyzed in this study. The majority of the patients included in the analysis were female without prior history of cardiovascular disease. The median age of the SCAD population was approximately 46 years. The most frequently affected artery in SCAD cases was the Left Anterior Descending artery. Intravascular ultrasound was utilized more frequently than other modalities of adjunctive imaging techniques. The most frequent complication was the distal propagation of hematoma. Despite the successful dilation achieved with the cutting balloon, in some cases stenting was required to provide additional support.ConclusionThe results of this analysis demonstrate that cutting balloon use in SCAD cases yields favorable outcomes.

Spontaneous coronary artery dissection (SCAD) is a rare but increasingly recognized cause of acute coronary syndrome (ACS) with recent advancements in cardiac imaging facilitating its identification. However, SCAD is still often misdiagnosed due to the absence of angiographic hallmarks in a significant number of cases, highlighting the importance of meticulous interpretation of angiographic findings and, when necessary, additional usage of intravascular imaging to verify changes in arterial wall integrity and identify specific pathoanatomical features associated with SCAD. Accurate diagnosis of SCAD is crucial, as the optimal management strategies for patients with SCAD differ from those with atherosclerotic coronary disease. Current treatment strategies favor a conservative approach, wherein intervention is reserved for cases with persistent ischemia, patients with high-risk coronary anatomy, or patients with hemodynamic instability. In this paper, we provide a preview of invasive imaging modalities and classical angiographic and intravascular imaging hallmarks that may facilitate proper SCAD diagnosis.

Spontaneous coronary artery dissection (SCAD) is a non-traumatic, non-atherosclerotic layering of the coronary artery wall due to the presence of a subintimal hematoma or an intimal tear with the creation of a false lumen that compresses the true lumen and restricts or obstructs the flow. Patients with SCAD and preserved coronary flow are treated conservatively according to the general recommendations. However, percutaneous coronary intervention should be considered in patients with artery occlusion and/or refractory ischemia. Stenting is associated with increased risks comprising stenting in the false lumen, in-stent thrombosis, and/or stent malappositon as well as antegrade or retrograde propagation of the intramural hematoma. Intracoronary imaging is of great value both for the diagnosis and treatment of SCAD. There is rising scrutiny on the use of cutting balloons in acute coronary syndrome caused by SCAD. The idea of using cutting balloons is to fenestrate the intima and drain the intramural hematoma. Our review presents an analysis of 17 published cases of cutting balloon (CB) use in SCAD. What is encouraging is that of the 12 published cases, in 11 Thrombolysis in Myocardial Infarction (TIMI) 3 flow was established with this technique, and TIMI 2 flow in one, without subsequent stent implantation. Four patients received a stent after the CB use, while one patient underwent CB angioplasty after hematoma propagation caused by stent implantation. In all cases, patients were asymptomatic at follow-up, with TIMI 3 flow.