A 32 -year-old woman presented with atypical chest pain. Treadmill test showed as a positive with low risk. Echocardiography was normal. There was no history of trauma or excessive physical exercise.
He had no other complaints and used no medication. Our patient was a smoker, wiith no history of hypertension, pregnancy, diabetes mellitus or hypercholesterolaemia.
Coronary artery angiography revealed a left main spontaneous dissection involving left anterior descending and left circumflex artery(Figure 1-4). Her hemodynamic status was stabil and without angina and dyspnea after coronary angiography.
How should I treat a left main spontaneous dissection involving left anterior descending and left circumflex artery ?
a- Medically
b- LMCA stenting
c- CABG
Dear Dr. Tatli:
given the patient's age of 32 she should be treated by total arterial surgical revascularization with a double mammary. You cannot predict how the dissection will behave in the future after all.
I don't thnk it was an spontaneus dissection, rather a iatrogeni dissection due to the diagnostic cathether.
Most of this cases are not asymptomatic and you need to seal the disection with LMCA stenting urgently.
In this case, since you'd need to do a full metal jacket of both LAD and Cx and the patient is assymptomatic, CABG is a good choice
Ignacio's point is well taken. As a surgeon I am confronted with so-called spontaneous dissections every once in a while. However, all of them (except in cases of pregnant women) have occurred after insertion of a catheter into the coronaries which by definition is a iatrogenic maneuver. It can happen but should be stated as a complication of a medical procedure.
This dissection was not iatrogenic, it was true SCAD, and the patient's hemodynamic status was normal during and after procedure .
Sincerely
Irrespective of cause, it is a dissection and requires urgent definitive management. I agree that CABG is the best option. Attempts to place a stent could turn a 'stable' situation into a catastrophe and delay optimal management.
It's very good question. It should be treated as it involved the Left main artery bifurcation and patient has got a positive stress test. you have got two options. First one is stenting, as the patient has got low syntax score. But it is a bit technically demanding procedure, as the dissection extended into the LAD and also involved the LCX ostium. If possible this could be a better option for this young guy. The second option is CABG, which can be done easily. But I would always advise the patient to go for revascularization either by PCI or CABG and of course will consider the patient's choice.
In my opinion from those low resolution angiographies it appears that this patient has separated origin of LCX and LAD. LCX has severe ostial stenosis which can be treated by PCI (single stent or V stenting). Better resolution and moving pictures might clarify further. (third and fourth images suspect this anatomy).
- Badges
- Science topic
- Similar topics
- Chemistry
- Pharmacology
- Pharmaceuticals
- Drugs