Author + information
- Published online April 1, 2019.
- Fernando Macaya, MD,
- Carlos H. Salazar, MD,
- María J. Pérez-Vizcayno, MD,
- Pablo Salinas, MD, PhD,
- Pilar Jiménez-Quevedo, MD, PhD,
- Luis Nombela-Franco, MD, PhD,
- María del Trigo, MD, PhD,
- Iván Núñez-Gil, MD, PhD,
- Antonio Fernández-Ortiz, MD, PhD,
- Carlos Macaya, MD, PhD,
- Javier Escaned, MD, PhD and
- Nieves Gonzalo, MD, PhD∗ ()
- ↵∗Interventional Cardiology, Hospital Clínico San Carlos, IDISSC and Universidad Complutense de Madrid, Calle Profesor Martín Lagos s/n, 28040 Madrid, Spain
Intracoronary imaging (ICI) provides unique visualization of the coronary lumen and arterial wall in spontaneous coronary artery dissection (SCAD) and aids diagnosis when angiography findings are ambiguous (1,2). However, spontaneously dissected arteries are prone to iatrogenic damage during vessel instrumentation (3). In this study, we aimed to provide real-world data from a single-center experience in the use of ICI in SCAD.
We reviewed a cohort of 81 patients diagnosed with SCAD; 28 of these patients had planned ICI. The outcomes measured were failure to assess the target lesion and iatrogenic damage, defined as worsening in Thrombolysis In Myocardial Infarction (TIMI) flow grade or new or /propagated dissection to an adjacent vessel.
From March 2006 to March 2017, 28 patients with SCAD at Hospital Clínico San Carlos in Madrid, Spain, were selected at the operator’s discretion for diagnostic confirmation with ICI; 5 patients required percutaneous coronary intervention (PCI) a priori. The patients were 51.6 ± 10.7 years of age, 82% were women, and none of the cases were pregnancy associated. The left anterior descending coronary artery was the involved vessel in 64%. The proximal segment was involved in 36%, and flow was impaired in 25%. In 6 patients, the intention to perform ICI produced iatrogenic damage: iatrogenic wire dissection (n = 1); iatrogenic guide catheter dissection (n = 1); propagation by wiring (n = 3); and propagation by advancement of the optical coherence tomography (OCT) catheter (n = 1). Of these patients, 5 (83%) required unplanned PCI. In 3 of the complications, assessment of the target lesion with ICI was ultimately precluded (incomplete advance of OCT or intravascular ultrasound [IVUS] catheter [n = 2] and proximal iatrogenic dissection [n = 1]). Diagnosis in these cases was confirmed by healing on repeat angiography.
Patients with complications presented more often with a type 1 angiographic pattern (3 of 6, 50%), whereas no patients had a type 3 pattern (p = 0.03). ICI was performed ad hoc during the first coronary angiogram in 16 patients (including all 6 patients with complications), whereas ICI was performed in a staged fashion in the remaining 12 patients (median deferral time 2.7 days; interquartile range [IQR]: 0.8 to 6.9 days). There was a significantly shorter time from symptom onset to ICI in patients with a complication (7.2 h [IQR: 2.8 to 44 h] vs. 53.9 h [IQR: 21.3 to 154.8 h] p = 0.04). There were no in-hospital complications in any case, and with a median follow-up of 6 years (range 1 to 11.5 years), there were no noticeable differences between patients with and without complications.
Overall, ICI failed to assess 10.7% (3 of 28) of the targeted SCAD lesions and resulted in complications in 21.4% (6 of 28). The 25 ICI studies performed were OCT (n = 17), IVUS (n = 2), or OCT in combination with IVUS (n = 6). The studies that used both OCT and IVUS were part of a research protocol; all these patients were free of complications. ICI was useful for upfront diagnostic confirmation in 31% of the entire SCAD cohort (25 of 81). In the remaining patients, angiography at presentation or documented vessel healing in the follow-up confirmed the diagnosis. ICI-related complications accounted for one-third of all PCI procedures performed in the entire cohort (5 complications out of a total of 15 PCI cases).
When considering use of ICI in SCAD, there are several factors to take into account (Table 1), the most important being the indication. Use of ICI should be reserved for ambiguous lesions (angiographic type 3 and some type 2) in segments amenable for imaging, as well as for guiding PCI (2). We found that complications occurred more in SCAD type 1. ICI should be discouraged when type 1 lesions are present; however, this study encompassed historical cases, which included the earliest use of ICI in SCAD (1). The insight gained from these early experiences has contributed to a better understanding of the angiographic appearance of SCAD and to the development of the angiographic classification that was subsequently proposed (4).
In addition to the historical reasons, another factor that may explain the high complication rate reported in this cohort is the inclusion of complications occurring before the use of imaging catheters (i.e., guiding catheter engagement and wiring propagation), which may represent a more realistic view of the harm attributable to the intention to perform ICI in this scenario.
Finally, the association between a shorter time from symptom onset to vessel manipulation and the occurrence of iatrogenic damage suggests that an iatrogenic complication in SCAD may have a time-dependent risk. Although these findings are hypothesis generating, they are in keeping with those of the study by Prakash et al. (3), where all iatrogenic dissections in SCAD occurred in the acute setting, and none occurred in follow-up studies.
Given its high spatial resolution, ICI is a valuable tool for diagnosing SCAD. Nevertheless, the potential risk of instrumenting an acutely dissected vessel should be carefully weighed, especially when the angiogram is characteristic of SCAD and when angiography is performed early in the course of the patient’s presentation.
Please note: Dr. Fernando Macaya is funded by the Fundación Interhospitalaria Investigación Cardiovascular. Dr. Nombela-Franco has served as a proctor for Abbott. Dr. Escaned has been a consultant and speaker at educational events for Abbott and Philips. Dr. Gonzalo has been a speaker at educational events for Abbott and Boston Scientific. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- 2019 American College of Cardiology Foundation
- Alfonso F.,
- Paulo M.,
- Gonzalo N.,
- et al.
- Macaya F.,
- Salinas P.,
- Gonzalo N.,
- Fernández-Ortiz A.,
- Macaya C.,
- Escaned J.
- Prakash R.,
- Starovoytov A.,
- Heydari M.,
- Mancini G.B.J.,
- Saw J.