Spontaneous coronary artery dissection percutaneous coronary intervention

Conservative management should be the first choice if emergent revascularization is not necessary. However, optimal management is in question due to insufficient clinical experience. There are some treatment options including conservative management, emergency revascularization (PCI or CABG), fibrinolytic therapy, mechanical hemodynamic support, and even cardiac transplantation.The preference of the approach should be tailored to the patient’s clinical status.

Conservative management should be first choice if emergent revascularization is not necessary. ^[1]

• However, optimal management is in question due to insufficient clinical experience.
• There are some treatment options including conservative management, emergency revascularization (PCI or CABG), fibrinolytic therapy, mechanical hemodynamic support, and even cardiac transplantation.
• Preference of the approach should be tailored to patient’s clinical status. ^{[2] [3] [4] [5]}

• Revascularization should be considered in case of acute myocardial infarction with symptoms or haemodynamic instability. ^[2]
• However, PCI is technically quite difficult with a high risk of complications.^{[6] [7]}
• Therefore, conservative management is recommended in patients with non-occlusive luminal obstruction, TIMI grade 3 flow, and a stable clinical condition.
• Performing PCI in SCAD is technically very difficult due to the arterial fragility.
• It can be quite challenging to keep the guidewire within the true lumen while crossing the lesion.
• Any instruments using in each stage such as wiring, angioplasty or stenting can enlarge the dissection and block side branches.
• In addition, these lesions are mostly require long stents resulting in higher rates of in stent restenosis.
• Furthermore, resorption of the intramural hematoma may lead to late stent malapposition and stent thrombosis.
• Therefore, stent implantation should only be performed in a strong clinical indication.
• It would be beneficial to perform procedure under the guidance of intracoronary imaging (IVUS, OCT).
• Although there is no evidence about the benefits of bioabsorbable stents, theoretically it seems to have advantages.^[8]