Login | Users Online: 395  
Home Print this page Email this page Small font sizeDefault font sizeIncrease font size   
Home | About us | Editorial board | Search | Ahead of print | Current Issue | Archives | Submit article | Instructions | Subscribe | Advertise | Contact us
 


 
Table of Contents
CASE REPORT
Year : 2012  |  Volume : 13  |  Issue : 4  |  Page : 149-154  

Spontaneous coronary artery dissection: Case report and review of literature


1 Department of Internal Medicine and Cardiology, Community Medical Center; The Wright Center for Graduate Medical Education, Pennsylvania, USA
2 Department of Internal Medicine and Cardiology, Community Medical Center; The Wright Center for Graduate Medical Education; The Commonwealth Medical College, Pennsylvania, USA

Date of Web Publication9-Jan-2013

Correspondence Address:
Monodeep Biswas
The Wright Center for Graduate Medical Education,501 Madison Ave, Scranton, Pennsylvania
USA
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1995-705X.105737

Rights and Permissions
   Abstract 

Spontaneous coronary artery dissection (SCAD) is an unusual cause of acute coronary syndrome or sudden cardiac death. SCAD has most frequently been described as presenting as an acute coronary syndrome in females during the peripartum period. It may also be associated with autoimmune and collagen vascular diseases, Marfan's syndrome, chest trauma, and intense physical exercise. The most common presentation of SCAD is the acute onset of severe chest pain associated with autonomic symptoms. This condition has a high mortality rate if not identified and treated promptly. Here, we present a case of SCAD presenting with stroke, followed by a brief review.

Keywords: Artery, coronary, dissection


How to cite this article:
Biswas M, Sethi A, Voyce SJ. Spontaneous coronary artery dissection: Case report and review of literature. Heart Views 2012;13:149-54

How to cite this URL:
Biswas M, Sethi A, Voyce SJ. Spontaneous coronary artery dissection: Case report and review of literature. Heart Views [serial online] 2012 [cited 2018 Nov 18];13:149-54. Available from: http://www.heartviews.org/text.asp?2012/13/4/149/105737


   Introduction Top


Spontaneous coronary artery dissection (SCAD) is an unusual cause of acute coronary syndrome (ACS) or sudden cardiac death. Here, we present a case of SCAD in a young man who presented with stroke, followed by a review of the literature on this rare clinical entity.


   The Case Top


A 26-year-old right-handed Caucasian male presented to the emergency department with the sudden onset of weakness of the left side of the body, associated with slurring of speech and a left-sided facial droop. He denied any symptoms of chest discomfort, palpitations, shortness of breath, diaphoresis, dizziness, nausea, vomiting, seizure activity, confusion, syncope, or visual disturbance. Past history was significant for an episode of deep venous thrombosis occurring 1 year prior to the current presentation. An extensive hypercoagulable workup, including protein C and S levels, factor V Leiden, antithrombin III, homocysteine levels, and antiphospholipid and anticardiolipin antibodies, was negative. There was no history of hypertension, diabetes mellitus, or dyslipidemia. The patient had no significant family history of premature coronary artery disease, but did admit to smoking one-half pack of cigarettes per day. He was taking an aspirin daily and had no known allergies. The review of symptoms was otherwise negative.

On admission, the patient with a normal body habitus appeared apprehensive but in no acute distress. Vital signs showed a regular pulse at 81 bpm and a blood pressure of 136/70 mm Hg. Carotid impulses were normal and the jugular venous pressure was not raised. Cardiac examination revealed normal heart sounds and there were no appreciable cardiac murmurs, rubs, or gallops. Lungs were clear. Neurologic examination revealed left-sided facial weakness with mild motor weakness and diminished touch and pain sensations on the left side of his body. Left-sided deep tendon reflexes were brisk and the left Babinski sign was positive.

Hypercoagulable workup was repeated and was again negative. The urine toxicology screen was negative. Carotid Doppler studies demonstrated no significant disease. Non-contrast computed tomography of the head was negative for intracerebral hemorrhage, and MRI of brain [Figure 1] demonstrated hyperintense signal on FLAIR imaging, consistent with a recent cerebral infarction in right middle cerebral artery (MCA) territory.
Figure 1: MRI (FLAIR) showing ischemic stroke in right MCA territory

Click here to view


The admission ECG showed normal sinus rhythm and age indeterminate anterior and inferior wall infarcts. Serial troponin I levels drawn on admission and at an eight-hourly interval thereafter were 0.02, 0.4, and 0.31 ng/ml, respectively (normal ≤0.05 ng/ml, indeterminate 0.06-0.5 ng/ml, positive >0.5 ng/ml). A transthoracic 2D echocardiogram [Figure 2] on admission demonstrated severe regional wall motion abnormality over the apical portion of interventricular septum associated with an apical mural thrombus. No valvular dysfunction was noted.
Figure 2: 2D echo showing apical mural thrombus in left ventricle

Click here to view


The patient was given tissue plasminogen activator (tPA) in the Emergency Department at a total dose of 0.9 mg/kg along with aspirin 325 mg orally. Unfractionated heparin was started 24 h later as per the hospital protocol. Oral metoprolol and coumadin were initiated 24 h after admission. A pharmacologic stress test with technetium-gated SPECT showed a large area of moderate to severe fixed perfusion defect at the tip of the apex extending to the distal anterior wall, distal inferior wall, and the distal interventricular septum, associated with severe regional wall motion abnormality. The ejection fraction was calculated at 46%.

Cardiac catheterization with coronary angiography was performed using a right radial artery approach. Coronary angiography showed a radiolucent linear defect suggestive of an intimal dissection involving the mid to distal segment of the left anterior descending artery with Thrombolysis in Myocardial Infarction (TIMI) grade III flow [Figure 3]. Mild left ventricular systolic dysfunction with apical wall dyskinesia and a small left ventricular aneurysm were present. The patient was maintained on medical management, including oral warfarin therapy [International Normalized Ratio (INR) maintained at 2-3], aspirin, beta-blocker, and statin, with close outpatient follow-up. He was provided advice on lifestyle modifications, including smoking cessation counseling. Follow-up coronary angiography at 6 months demonstrated a stable appearance of the coronary dissection. His medical management was continued, but warfarin was discontinued after 6 months. He remains well 10 months since his initial event.
Figure 3: Coronary angiogram showing intimal dissection flap with preserved flow in distal LAD

Click here to view



   Review Top


The earliest report of SCAD was published in 1931 and at that time the disease entity was referred to as "dissecting aneurysm of coronary artery."[1] Isolated dissection of the coronary artery is a relatively uncommon condition that usually presents as an ACS or sudden cardiac death, with a reported mortality of 80%. [2] Coronary artery dissection is termed spontaneous once secondary causes like coronary interventions, cardiac surgery, trauma, and aortic dissection have been excluded.

Forker et al. reported the first known survivor, a 56-year-old man who had a right coronary artery dissection with atherosclerotic vascular disease. [3] Claudon et al. in a seminal article reviewed 24 cases and concluded that the condition is common in young, postpartum women. [4],[5] The reported incidence of SCAD varies from 0.1% to 1.1% by angiography. [6] Approximately 500 cases have been documented in the medical literature so far as there is a high incidence of sudden cardiac death associated with the condition. [7] The Western Denmark Heart registry reported 22 cases of SCAD out of a total of 11,175 ACS patients, and 77% of them were women. [8] The pathophysiology relates to the presence of a hematoma in the media of the coronary artery that compromises blood flow in the true lumen of the vessel. The inciting event is usually an intimal tear which allows blood entry into the media. If coronary blood flow is sufficiently compromised, the myocardium supplied by the affected artery may become ischemic or infarcted. The present article aims to review the existing literature related to the topic and provide a comprehensive review on this rare disease entity.


   Etiology and Associations Top


SCAD has been reported most commonly in women during the peripartum period presumably due to hypertensive trauma during childbirth. The increased incidence of SCAD in pregnancy and postpartum period is thought to be due to decreased collagen production or enhanced degradation in intima and media of vessel wall in the postpartum period, increased shear stress on arterial wall due to augmented cardiac output, inherent hypercoagulability in peripartum state, and hemorrhagic disruption of vasa vasorum. [9] Progesterone in pregnancy causes increased fragmentation of reticular fibers along with decreased acid mucopolysachcharides, causing weakening of vessel wall. A comprehensive review by Koul et al. has shown that SCAD is more common in multiparous women, usually more than 30 years of age, and involves the left anterior descending artery (LAD). In most of the cases, and about one-third of the cases show multivessel coronary artery dissection. [10]

Shamloo et al. recently did a systematic analysis of all published cases and concluded thus: a) About 20% of cases were diagnosed postmortem and the rest by coronary angiogram; b) isolated single vessel involvement was the most frequent lesion; c) early intervention (either stent or bypass graft surgery) strategy had a superior outcome compared to conservative management; and d) administration of thrombolytics (before diagnosis of SCAD) resulted in worsening of condition in 60% of patients. [11]

Vessel wall weakness is an important substrate for development of spontaneous coronary artery dissection, be it in pregnant states or as a part of systemic inflammation. It may also be associated with autoimmune and collagen vascular diseases, Marfan's syndrome,  Ehlers-Danlos syndrome More Details, or intense physical exercise [12] [Table 1]. [13],[14],[15],[16],[17],[18],[19],[20] Anecdotal relationships have been reported with clonidine and cabergoline intake. [21],[22]
Table 1: Etiology and associations of SCAD[13-20]

Click here to view


Clinical presentation

The most common presentation of SCAD is the acute onset of severe chest pain associated with autonomic symptoms such as diaphoresis, palpitations, and either hyper- or hypotension. Asymptomatic cases are rare. The condition carries a high mortality if not identified and treated promptly. SCAD presenting as ischemic stroke is extremely unusual with only two cases reported in the medical literature. [12],[23]

Pathology and pathophysiology

The pathology of SCAD usually shows a dissection plane between the media and the adventitia of the artery due to cystic medial necrosis or hemorrhagic disruption of the vasa vasorum. [23] Cystic medial necrosis is a rare finding and usually involves focal fragmentation and loss of elastic fibers and smooth muscle cells of the media, associated with deposits of varying amount of acid mucopolysaccharides. The lesion is typically seen in the vessel wall of patients with Marfan's syndrome, systemic hypertension, and as a part of aging process. [24] The presence of an eosinophilic infiltrate in adventitia has also been described, particularly in non-atherosclerotic SCAD. [25],[26]

The histology of approximately 50% of dissections (both associated with peripartum state and those without) shows a predominant eosinophilic infiltrate. The presence of eosinophils has been thought of as a secondary reactive phenomenon rather than a primary etiological association. However, the tissue damaging effects of eosinophil granule components along with their presence in the vessel wall have been used to explain the potential role of eosinophils in the dissection process. Eosinophil granules contain collagenase, acid phosphatase, major basic protein, arylsulfatase, and beta-glucoronidase, which can significantly damage the collagen fibers of the vessel wall and possibly initiate a dissection process. In fact, SCAD has been reported in cases with Churg-Strauss syndrome, [27] drug-induced eosinophilia, [28] and in a case with peripheral eosinophilia. There is an anecdotal report where patient was treated with immunosuppressants like prednisone and cytoxan to counter the eosinophil-mediated periadventitial inflammation with favorable results. [29]

Prognosis

Dissection of the left main coronary artery or multivessel dissection carries a particularly poor prognosis. [30],[31],[32],[34] Atherosclerotic etiology and male gender has comparatively better prognosis in this condition. [35] Recurrent coronary dissection has been reported in 50% of patients mostly within 1 or 2 months. Recurrent SCAD in subsequent pregnancies has not been reported yet. [36]

Management

The diagnosis is usually confirmed by coronary angiography. Common angiographic findings include intimal flap, two separate communicating lumens, multiple dissecting lines, and coronary aneurysm communicating with the lumen. Nitroglycerin-resistant segmental narrowing in a young female without any cardiac risks can be a presumptive diagnosis for SCAD. [37],[38] LAD involvement is more common in females, whereas right coronary artery (RCA) involvement is more common in males. Dissection of left main is rare. [39]

In cases requiring percutaneous coronary intervention (PCI), coronary dissection presents a unique challenge as it may prove difficult to identify the true arterial lumen and secure proper guidewire placement. Precise localization of the site and extent of dissection and identification of the true lumen may require intravascular imaging modalities such as intravascular ultrasound (IVUS) or optical coherence tomography (OCT). IVUS has been used to visualize surface morphology, plaque architecture, and lumen size during stent implantation. The image resolution of IVUS is 100-150 μm, hence it is poor in detecting detailed structures like intimal flaps, thrombus, stent malposition, and tissue prolapse during stent implantation. ChromaFlo, a modality that shows blood flow by comparing sequential axial IVUS images and interpreting any differences in the position of echogenic blood particles as blood flow, has been used for optimal therapeutic strategies during PCI. [40]

OCT is a promising new technology that provides high-resolution (10-20 μm) intraluminal images with almost ultra-structural details. It consists of a fiberoptic wire that emits light in the near-infrared spectrum (1250-1350 nm) and records reflected light signals while rotating and being simultaneously pulled back along the long axis of a coronary vessel. OCT, however, has a poor penetration depth, but its high resolution allows visualization of microstructural features such as intimal tears, thrombus, or stent malposition. Unlike conventional time domain-OCT (TD-OCT) which requires coronary artery occlusion during imaging, newer generation frequency domain-OCT (FD-OCT) has faster image acquisition and greater scan depths without sacrificing the resolution of the image. OCT wire has a smaller diameter compared to the IVUS probe and has been described by Lim et al. as a useful adjunct in the management of patients with SCAD. [41] Recently, Zheng and colleagues have used dual-source computed tomography as a non-invasive method to diagnose SCAD. [42] Multi-detector CT (MDCT) can be also used to examine the extent and thickness of hematoma as well as to document healing and follow-up. [43]

There are no guidelines regarding optimal treatment of this condition. Treatment is guided by the clinical symptoms, extent and location of the dissection, and the hemodynamic status of the patient. Percutaneous coronary strategies are reasonable in acute cases with proximal dissection (of major epicardial vessels) and arterial occlusion in order to restore coronary perfusion and hemodynamic stability. Dissection of distal vessels of small caliber or with preserved blood flow (as in our case) without clinical or ECG changes may occur.

No data exists regarding use of drug-eluting stents (DES) over bare metal stents, although some have voiced concern that DES may adversely affect arterial healing. Cannulation of the false lumen and coronary perforation/occlusion are described as the potential complications of attempted intervention in SCAD. The major difficulty of stenting in the setting is that the intramural hematoma may be displaced either proximally or distally by the stent and results in luminal occlusion. One strategy is to deploy multiple stents, distal to proximal, covering the dissected portion of the artery; however, the risk is a greater chance of subsequent in-stent restenosis. The other strategy is to stent the entry point of the dissection if it can be visualized and to close the intimal defect with a stent and let the hematoma heal on its own. This, however, requires precise localization of the dissection entry point, which may be possible with OCT as described above.

Conservative medical therapy is reasonable in cases of distal dissection with preserved coronary flow. IVUS has been used to document healing of SCAD in select cases. [44] Reduction of vessel wall sheer stress with the use of beta-blockade has been described as a reasonable therapeutic choice. [45] The role of long-term antiplatelets in patients with SCAD, not receiving stent, has never been examined in a clinical trial; however, there are anecdotal evidences of benefit. [45] Use of heparin, thrombolysis, and glycoprotein IIb-IIIa inhibitors during the acute presentation is controversial. [46],[47],[48],[49] The risks are extension of dissection or hematoma, and there is risk of postpartum hemorrhage or fetal intracranial bleeding during pregnancy and postpartum period. [50]

Surgical revascularization is usually restricted to hemodynamically unstable cases where percutaneous coronary intervention has failed (such as complete vessel occlusion due to expanding dissection) or is deemed impossible (such as multivessel long segment dissection with good distal segment suitable for bypass). [51]

A pubmed search yielded in excess of 500 articles, mostly case reports and case series. An inherent difficulty in understanding the natural history and prognosis of the condition is the rarity of its occurrence. Large-scale multicentric studies are necessary and novel strategies such as community-based social networking may be implemented to gather information about this disease. [52] The Discovery trial has been initiated as the first prospective registry to look into the incidence, therapeutic options, and outcome analysis for SCAD. [53]

Clinicians should keep in mind the possibility of SCAD in case of a pregnant woman with ACS. There is no apparent contraindication for using the usual medications like antiplatelets or beta-blockers, however ACE inhibitors should be avoided. Coronary angiogram, if necessary, should preferably be performed through a radial access along with a lead sheet over abdomen and pelvis of the patient, as it limits fetal exposure to radiation of less than 5 rad.

Internists as well as cardiologists should be familiar with the clinical presentation as well as angiographic appearance of SCAD and be aware of the treatment options. An understanding of the inherent difficulties and potential complications of manipulating dissecting coronary arteries should help guide the risk/benefit assessment of the therapeutic decision-making when confronted with this unusual angiographic finding.

 
   References Top

1.Pretty HC. Dissecting aneurysm of coronary artery in a woman aged 42: Rupture. Br Med J 1931;1:667.  Back to cited text no. 1
    
2.Jorgensen MB, Aharonian V, Mansukhani P, Mahrer PR. Spontaneous coronary dissection: A cluster of cases with this rare finding. Am Heart J 1994;127:1382-7.  Back to cited text no. 2
[PUBMED]    
3.Forker AD, Rosenlof RC, Weaver WF, Carveth SW, Reese HE. Primary dissecting aneurysm of the right coronary artery with survival. Chest 1973;64:656-8.  Back to cited text no. 3
[PUBMED]    
4.Dhawan R, Singh G, Fesniak H. Spontaneous coronary artery dissection: The clinical spectrum. Angiology 2002;53:89-93.  Back to cited text no. 4
[PUBMED]    
5.Claudon DC, Claudon DB, Edwards JE. Primary, dissecting aneurysm of mronary artery, a cause of acute myocardial ischemia. Circulation 1972;45:259-66.  Back to cited text no. 5
    
6.Oliveira SM, Gonçalves A, Dias P, Maciel MJ. Spontaneous coronary artery dissection: A diagnosis to consider in acute coronary syndromes. Rev Port Cardiol 2009;28:707-13.  Back to cited text no. 6
    
7.Mazullah K, Amrit G, Monika B. Spontaneous coronary artery dissection: Case series and review. J Invasive Cardiol 2008;20:553-9.  Back to cited text no. 7
    
8.Mortensen KH, Thuesen L, Kristensen IB, Christiansen EH. Spontaneous coronary artery dissection: A Western Denmark heart registry study. Catheter Cardiovasc Interv 2009;74:710-7.  Back to cited text no. 8
[PUBMED]    
9.Appleby CE, Barolet A, Ing D, Ross J, Schwartz L, Seidelin P, et al. Contemporary management of pregnancy-related coronary artery dissection: A single-centre experience and literature review. Exp Clin Cardiol 2009;14:e8-e16.  Back to cited text no. 9
[PUBMED]    
10.Koul AK, Hollander G, Moskovits N, Frankel R, Herrera L, Shani J. Coronary artery dissection during pregnancy and the postpartum period: Two case reports and review of literature. Catheter Cardiovasc Interv 2001;52:88-94.  Back to cited text no. 10
[PUBMED]    
11.Shamloo BK, Chintala RS, Nasur A, Ghazvini M, Shariat P, Diggs JA, et al. Spontaneous coronary artery dissection: Aggressive vs. conservative therapy. J Invasive Cardiol 2010;22:222-8.  Back to cited text no. 11
[PUBMED]    
12.Rajendra N, Lim F, Shaukat N. Spontaneous coronary artery dissection presenting as an ischaemic stroke in a middle-aged man with anti-cardiolipin antibodies: A case report. J Med Case Rep 2010;4:94.  Back to cited text no. 12
[PUBMED]    
13.Schmid J, Auer J. Spontaneous coronary artery dissection in a young man-case report. J Cardiothorac Surg 2011;6:22.  Back to cited text no. 13
    
14.Mora B, Urbanek B, Loewe C, Grimm M, Dworschak M. Position dependent right ventricular dysfunction caused by a giant right coronary artery aneurysm. Wien Klin Wochenschr 2011;123:58-60.  Back to cited text no. 14
[PUBMED]    
15.El-Sherief K, Rashidian A, Srikanth S. Spontaneous coronary artery dissection after intense weightlifting UCSF fresno department of cardiology. Catheter Cardiovasc Interv 2011;78:223-7.  Back to cited text no. 15
[PUBMED]    
16.Karabay CY, Biteker M, Zehir R, Bezgin T, Tanboga H, Can MM, et al. Multiple spontaneous coronary artery dissection associated with Trousseau's syndrome. Cardiol J 2010;17:625-7.  Back to cited text no. 16
[PUBMED]    
17.Ehya H, Weitzner S. Postpartum dissecting aneurysm of coronary arteries in a patient with sarcoidosis. South Med J 1980;73:87-8.  Back to cited text no. 17
[PUBMED]    
18.Chu KH, Menapace FJ, Blankenship JC, Hausch R, Harrington T. Polyarteritis nodosa presenting as acute myocardial infarction with coronary dissection. Cathet Cardiovasc Diagn 1998;44:320-4.  Back to cited text no. 18
[PUBMED]    
19.Aldoboni AH, Hamza EA, Majdi K, Ngibzadhe M, Palasaidi S, Moayed DA. Spontaneous dissection of coronary artery treated by primary stenting as the first presentation of systemic lupus erythematosus. J Invasive Cardiol 2002;14:694-6.  Back to cited text no. 19
[PUBMED]    
20.Lee CC, Fang CY, Huang CC, Ng SH, Yip HK, Ko SF. Computed tomography angiographic demonstration of an unexpected left main coronary artery dissection in a patient with polycystic kidney disease. J Thorac Imaging 2011;26:W4-6.  Back to cited text no. 20
    
21.Mehta NK, Malkani S, Ockene I. Spontaneous coronary artery dissection during cabergoline therapy. Tex Heart Inst J 2012;39:92-4.  Back to cited text no. 21
[PUBMED]    
22.Cilingiroðlu M, Rahman S, Helmy T, Seshiah P. Spontaneous right coronary artery dissection possibly associated with clonidine transdermal patch. Turk Kardiyol Dern Ars 2011;39:224-7.  Back to cited text no. 22
    
23.Acikel S, Yildirir A, Muderrisoglu H. Spontaneous coronary artery dissection presenting as an ischaemic stroke in a middle-aged man with anti-cardiolipin antibodies. Int J Cardiol 2009;134:e53-5.  Back to cited text no. 23
    
24.Conraads VM. Spontaneous dissection of three major coronary arteries subsequent to cystic medial necrosis. Chest 1999;116:1473-5.  Back to cited text no. 24
    
25.Borczuk AC, van Hoeven KH, Factor SM. Review and hypothesis: The eosinophil and peripartum heart disease (myocarditis and coronary artery dissection)-coincidence or pathogenetic significance? Cardiovasc Res 1997;33:527-32.  Back to cited text no. 25
    
26.Hoye A. Spontaneous coronary artery dissection: Time for a concerted effort to better understand this rare condition. J Invasive Cardiol 2010;22:229-30.  Back to cited text no. 26
    
27.Hunsaker JC, O'Connor WN, Lie JT. Spontaneous coronary dissection and isolated eosinophilic coronary arteritis: Sudden cardiac death in a patient with limited variant of Churg-Strauss syndrome. Mayo Clin Proc 1992;67:761-6.  Back to cited text no. 27
    
28.Saunders SL, Ford SE. Primary coronary dissection possibly related to drug hypersensitivity in a male. Can J Cardiol 1991;7:138-40.  Back to cited text no. 28
    
29.Koller PT, Cliffe CM, Ridley DJ. Immunosuppressive therapy for peripartum type spontaneous coronary artery dissection: Case report and review. Clin Cardiol 1998;21:40-6.  Back to cited text no. 29
    
30.Basso C, Morgagni GL, Thiene G. Spontaneous coronary artery dissection: A neglected cause of acute myocardial ischemia and sudden death. Heart 1996;75:451-4.  Back to cited text no. 30
    
31.Marcoff L, Popescu A, Price L, Leidig GA Jr, Clay AW, Kelly JJ 3 rd , et al. Spontaneous coronary artery dissection in a postpartum woman presenting with chest pain. Am J Emerg Med 2010;28:641.e5-7.  Back to cited text no. 31
    
32.Dakik HA, Nader GA, Arja WA, Sawaya J, Gharzuddine W. Asymptomatic spontaneous coronary artery dissection. Clin Cardiol 2010;33:E40-2.  Back to cited text no. 32
    
33.Shankarappa RK, Panneerselvam A, Dwarakaprasad R, Karur S, Krishnanaik GB, Nanjappa MC. Spontaneous asymptomatic coronary artery dissection in a young man. J Cardiol 2009;54:499-502.  Back to cited text no. 33
    
34.DeMaio SJ, Kinsella SH, Silverman ME. Clinical course and longterm prognosis of spontaneous coronary artery dissection. Am J Cardiol 1989;64:471-4.  Back to cited text no. 34
    
35.Celik SK, Sagcan A, Altintig A, Yuksel M, Akin M, Kultursay H. Primary spontaneous coronary artery dissections in atherosclerotic patients. Report of nine cases with review of the pertinent literature. Eur J Cardiothorac Surg 2001;20:573-6.  Back to cited text no. 35
    
36.Kansara P, Graham S. Spontaneous coronary artery dissection: Case series with extended follow up. J Invasive Cardiol 2011;23:76-80.  Back to cited text no. 36
    
37.Kamineni R, Sadhu A, Alpert J. Spontaneous coronary artery dissection: Report of two cases and a 50-year review of the literature. Cardiol Rev 2002;10:279-84.  Back to cited text no. 37
    
38.Zampieri P, Aggio S, Roncon L, Rinuncini M, Canova C, Zanazzi G, et al. Follow up after spontaneous coronary artery dissection: A report of five cases. Heart 1996;75:206-9.  Back to cited text no. 38
    
39.Verma PK, Sandhu MS, Mittal BR, Aggarwal N, Kumar A, Mayank M, et al. Large spontaneous coronary artery dissections: A study of three cases, literature review and possible therapeutic strategies. Angiology 2004;55:309-18.  Back to cited text no. 39
    
40.Deftereos S, Giannopoulos G, Mavrogianni A, Sykiotis A, Pyrgakis V, Bobotis G. Role of grey-scale intravascular ultrasound and ChromaFlo in deciding on treatment approach for spontaneous coronary dissection in a young woman. Hellenic J Cardiol 2011;52:364-6.  Back to cited text no. 40
    
41.Lim C, Banning A, Channon K. Optical coherence tomography in the diagnosis and treatment of spontaneous coronary artery dissection. J Invasive Cardiol 2010;22:559-60.  Back to cited text no. 41
    
42.Zheng M, Li J, Xu J, Chen K, Zhao B, Huan Y. Spontaneous dissection of left anterior descending coronary artery: The diagnostic role of dual-source computed tomography. J Thorac Imaging 2010;25:W79-81.  Back to cited text no. 42
    
43.Manghat NE, Morgan-Hughes GJ, Roobottom CA. Spontaneous coronary artery dissection appearance and follow up on multi-detector row CT coronary angiography. Clin Radiol 2005;60:1120-5.  Back to cited text no. 43
    
44.Porto I, Aurigemma C, Pennestrì F, Rebuzzi AG. Intravascular ultrasound-documented healing of spontaneous coronary artery dissection. Circ Cardiovasc Interv 2010;3:519-22.  Back to cited text no. 44
    
45.Choi JW, Davidson CJ. Spontaneous multivessel coronary artery dissection in a long-distance runner successfully treated with oral antiplatelet therapy. J Invasive Cardiol 2002;14:675-8.  Back to cited text no. 45
    
46.Behnam R, Tillinghast S. Thrombolytic therapy in spontaneous coronary artery dissection. Clin Cardiol 1991;14:611-4.  Back to cited text no. 46
    
47.Cheung S, Mithani V, Watson RM. Healing of spontaneous coronary dissection in the context of glycoprotein IIB/IIIA inhibitor therapy: A case report. Catheter Cardiovasc Interv 2000;51:95-100.  Back to cited text no. 47
    
48.Karaahmet T, Tigen K, Gurel E, Cevik C, Mutlu B, Baºaran Y. Spontaneous dissection of the left main coronary artery regressed with thrombolytic therapy: Evaluation with multislice computed tomography angiography. Anadolu Kardiyol Derg 2009;9:E2-3.  Back to cited text no. 48
    
49.Zupan I, Noc M, Trinkaus D, Popovic M. Double vessel extension of spontaneous left main coronary artery dissection in young women treated with thrombolytics. Catheter Cardiovasc Interv 2001;52:226-30.  Back to cited text no. 49
    
50.Sebastian C, Scherlag M, Kugelmass A, Schechter E. Primary stent implantation for acute myocardial infarction during pregnancy: Use of abciximab, ticlopidine, and aspirin. Cathet Cardiovasc Diagn1998;45:275-9.  Back to cited text no. 50
    
51.Motreff P, Souteyrand G, Dauphin C, Eschalier R, Cassagnes J, Lusson JR. Management of spontaneous coronary artery dissection: Review of the literature and discussion based on a series of 12 young women with acute coronary syndrome. Cardiology 2010;115:10-8.  Back to cited text no. 51
    
52.Tweet MS, Gulati R, Aase LA, Hayes SN. Spontaneous coronary artery dissection: A disease-specific, social networking community-initiated study. Mayo Clin Proc 2011;86:845-50.  Back to cited text no. 52
    
53.Fontanelli A, Olivari Z, La Vecchia L, Basso C, Pagliani L, Marzocchi A, et al. Spontaneous dissections of coronary arteries and acute coronary syndromes: Rationale and design of the DISCOVERY, a multicenter prospective registry with a case-control group. J Cardiovasc Med (Hagerstown) 2009;10:94-9.  Back to cited text no. 53
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1]


This article has been cited by
1 Repeat Coronary Artery Dissection in Pregnancy: A Case Report and Review of the Literature
Casey P. Bitting,Ross E. Zumwalt
Journal of Forensic Sciences. 2017;
[Pubmed] | [DOI]
2 Spontaneous coronary artery dissection causing acute coronary syndrome in a young patient without risk factors
Parag Chevli,Fnu Kelash,Pragnesh Gadhvi,Sreeram Grandhi,Amer Syed
Journal of Community Hospital Internal Medicine Perspectives. 2014; 4(0)
[Pubmed] | [DOI]



 

Top
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
    Abstract
   Introduction
   The Case
   Review
    Etiology and Ass...
    References
    Article Figures
    Article Tables

 Article Access Statistics
    Viewed3967    
    Printed146    
    Emailed4    
    PDF Downloaded131    
    Comments [Add]    
    Cited by others 2    

Recommend this journal