Spontaneous coronary artery dissection: Acute findings on coronary computed tomography angiography

Abstract

Background: The coronary computed tomography angiography features of acute spontaneous coronary artery dissection, an important cause of acute coronary syndrome in young women, have not been assessed.

Methods: The "Virtual" Multicenter Mayo Clinic Spontaneous Coronary Artery Dissection Registry was established in 2010 and includes retrospective and prospective patient data. Retrospective assessment of acute coronary computed tomography angiography images was performed for 14 patients (16 vessels) who had images performed within two days of invasive coronary angiography diagnosis of acute spontaneous coronary artery dissection.

Results: Four pertinent diagnostic coronary features of acute spontaneous coronary artery dissection were observed in order of prevalence: 1) abrupt luminal stenosis (64%); 2) intramural hematoma (50%); 3) tapered luminal stenosis (36%); and 4) dissection (14%). Additional findings include epicardial fat stranding (42%), coronary tortuosity (29%), and coronary bridge (14%). Fifty percent of patients had myocardial hypoperfusion in the myocardial distribution of the dissected coronary artery.

Conclusions: We define key coronary computed tomography angiography features of acute spontaneous coronary artery dissection, the most common of which are abrupt luminal stenosis and intramural hematoma. Importantly, intramural hematoma appears similar to noncalcified atherosclerotic plaque, emphasizing the importance of invasive coronary angiography for acute diagnosis of spontaneous coronary artery dissection until the sensitivity and specificity of coronary computed tomography angiography is better understood.

Keywords: Coronary computed tomography angiography; myocardial infarction; spontaneous coronary artery dissection; women.

Conflict of interest statement

Conflict of interest

PJM Best received modest Speakers Bureau fees from Abbott Vascular (from a panel discussion at SCAI sponsored by Abbott). The other authors have no disclosures to report.

Figures

Figure 1

Study patient selection process. CA: Invasive coronary angiography; CCTA: coronary computed tomography angiography; ECG: electrocardiogram; SCAD: spontaneous coronary artery dissection.

Figure 2

Features of acute spontaneous coronary artery dissection on coronary computed tomography angiography.

Figure 3

Intramural hematoma and long tapered luminal stenosis ((a) and (b), arrows) on coronary computed tomography angiography (CCTA) of acute left anterior descending (LAD) coronary artery spontaneous coronary artery dissection. Corresponding invasive coronary angiography demonstrating poor LAD distal blood flow (c) and three-dimensional CCTA reconstruction (d).

Figure 4

Intramural hematoma and long tapered luminal stenosis ((a), arrows) with epicardial fat stranding ((b) and (c), arrows) on coronary computed tomography angiography (CCTA) of acute left anterior descending (LAD) coronary artery spontaneous coronary artery dissection (SCAD) with corresponding invasive coronary angiography ((d), arrow). Dissection ((e) and (f), ovals) due to SCAD of the left circumflex coronary artery on CCTA with corresponding invasive coronary angiography ((g), oval).

Figure 5

Intramural hematoma and abrupt luminal stenosis ((a)–(d), arrows) on coronary computed tomography angiography (CCTA) of acute left anterior descending (LAD) coronary artery spontaneous coronary artery dissection. Corresponding three-dimensional CCTA reconstruction (d).

Figure 6

Frequency of primary and secondary features of acute spontaneous coronary artery dissection on coronary computed tomography angiography.

Figure 7

Appearance of intramural hematoma in the left circumflex coronary artery ((a)–(c), arrows) suggestive of spontaneous coronary artery dissection (SCAD) with corresponding renal fibromuscular dysplasia (FMD; (d), oval) in a patient with history of non-ST-elevation myocardial infarction who did not undergo invasive coronary angiography as an initial strategy. Subsequent invasive coronary angiography with optical coherence tomography demonstrated that the patient had noncalcified atherosclerotic plaque, not SCAD, ((e), arrow; (f), asterisk) despite confirmation of FMD ((g), arrow).