BACKGROUND
SUMMARY
Spontaneous coronary artery dissection (SCAD) is a rare, but perhaps underestimate cause of acute coronary syndrome, and recent studies reported a surge in the recognition of this condition, particularly in young women presenting with acute coronary syndrome. However, despite the latest insights in epidemiological knowledge and advance in diagnostic capability using intracoronary tomographic imaging, the management of SCAD remains unsettled. Bioresorbable vascular scaffold (BRS) might represent an attractive therapeutic tool in SCAD, allowing for transient sealing of intimal flap and scaffolding of intramural hematoma, overcoming late pathology related to metallic stent. At the same time, BRS implantation could reduce the risk of late malapposition due to intramural hematoma reabsorption. The aim of this study was to investigate feasibility and safety of BRS in SCAD.
METHODS
In a multicenter prospective registry, 27 patients affected by SCAD presenting with ACS and treated by BRS between 2013 and 2015 were included. Diagnosis of SCAD was based on angiography when pathognomonic angiographic appearance with contrast dye staining of the arterial wall with multiple radiolucent lumens was appreciated (type I of Saw Classification); smooth and diffuse narrowing with abrupt change in arterial caliber, with demarcation from normal diameter to diffuse narrowing, or long and linear stenosis, or hazy long lesions (type II and III of Saw classification) were considered as SCAD, especially in absence of atherosclerotic changes in the other vessels and high clinical suspicion of SCAD; when angiography was considered inconclusive diagnosis was definitely accomplished by IVUS Inclusion criteria were: SCAD with ongoing ischemia, or flow-limiting, or severe lumen narrowing and proximal location, visual estimated RVD > 2.5 mm < 4.0 mm. Exclusion criteria were: pregnancy, contraindication to DAPT, hyper-reactivity to poly-lactate. In SCAD type II and III, IVUS/OCT was strongly suggested to confirm diagnosis. Angiographic success was defined as successful delivery of BRS at intended target lesion with TIMI-3 flow and stenosis <30%; clinical procedural success (patient level) as angiographic success without the occurrence of cardiac death, myocardial infarction/re-infarction or target vessel revascularization (TVR) during the hospital stay. Clinical plus CT-scan or angiography was planned at 12-months follow-up.
RESULTS
All but 2 patients were female, mean age 48±9 years; risk factors for SCAD were identified in 14 patients. Presentation was STEMI (48%), NSTE-ACS (37%), or life-threatening arrhythmias (15%). LAD was the most common culprit vessel (69%); 2 patients underwent BRS on 2 vessels: thus, 29 coronary arteries were treated. Revascularization was accomplished with 1 to 5 BRS per patient (mean total scaffold length 57±28 mm). IVUS guidance was used in 45%, post-dilatation in 72%. Device success was obtained in 100% of cases. Angiographic success was achieved in 28 of 29 (97%) lesions. Procedural success was achieved in 25 of 27 (93%) patients. No in-hospital deaths or non-fatal myocardial re-infarction were observed; 1 patient underwent TVR due to symptomatic SCAD progression at scaffolds’ edge. At 1-year follow-up, 1 TVR due to asymptomatic BRS recoil was observed. Coronary imaging (either invasive or not invasive) follow- up was performed in 15 patients with 1 year follow up showing BVS patency in 14 of 15 cases; one case of recurrent SCAD and one case of SCAD persistence were registered.
CONCLUSIONS
Our study, on the largest cohort of patients to date, suggests the feasibility and safety of bio- resorbable coronary scaffolds in Spontaneous Coronary Artery Dissection, with high rates of
angiographic and procedural success, and favorable 1-year results. Nevertheless, longer evaluation in larger studies is needed
