P76 A ‘PARACHUTE EFFECT’ MOCKINGLY SEALING A SPONTANEOUS CORONARY ARTERY DISSECTION

Abstract

Abstract We present a case of a 38–year–old female admitted for Non ST–Elevation Myocardial Infarction. 15 days before the patient experienced an inferior ST–Elevation Myocardial Infarction and underwent primary Percutaneous Coronary Intervention with 2 drug–eluting stent (DES) in the mid–Right Coronary Artery (RCA). At presentation ECG and echocardiogram was negative for myocardial ischemia. For the typical chest pain, an urgent coronary angiography (CA) was performed. The previously stented RCA did not show any significant stenosis but a posterolateral branch appeared occluded at the ostium, with a retrograde flow from the left anterior descending artery. However, suspecting a dissection distally to the stents previously implanted, an Optical Coherence Tomography (OCT) was performed after 2 guidewires placement. The presence of two guidewires and the contrast medium pushing from inside–out caused a ‘sealing effect’ of the intima to the media, hence hiding the presence of dissection. The day after, a new chest pain episode associated with transient ST–segment elevation in the inferior leads warranted a new CA. Another OCT of the RCA was performed, this time using a single guidewire: a clear imaging confirmed the spontaneous coronary artery dissection (SCAD) presence. To have a better understanding of the vessel morphology an Intravascular Ultrasound (IVUS) analysis was carried out and even this imaging modality confirmed the presence of a true and false lumen. The interventional cardiologist decided to treat the dissection with two overlapping drug–eluting stents and a TIMI–3 flow was restored, with the complete resolution of the symptoms The patient was discharged after 5 days with dual antiplatelet therapy and statin. At the 24 month follow–up she was still asymptomatic. SCAD expertise is of utmost importance in recognizing this entity and, perhaps, this is the reason why it is still underdiagnosed, also in view of the frequent absence of hallmarks at CA. This is a case in which a complete imaging evaluation (CA + OCT + IVUS) has discovered and documented a SCAD after a recent stent implantation and in which the exclusive acquisition of angiograms by inexperienced operators could have missed the dissection.