PCI may benefit high-risk patients with spontaneous coronary artery dissection
More extensive stenting improved coronary perfusion and reduced myocardial injury among high-risk patients with spontaneous coronary artery dissection, but was linked to elevated risk for procedural complications, researchers reported.
“Taken together, these data suggest that PCI should remain the reserve of high-risk [spontaneous coronary artery dissection] presentations,” Deevia Kotecha, of the University of Leicester, U.K., and colleagues wrote in Heart.
For the observational study, Kotecha and colleagues analyzed 215 patients with spontaneous coronary artery dissection (SCAD; 94% women) from three national cohort studies who underwent PCI. The researchers also analyzed a matched cohort of 221 conservatively managed patients with SCAD. Outcomes of interest included PCI complications, serious PCI complications, MACCE and recurrence of SCAD.
Overall, patients who received PCI presented at high risk, with only 8.8% not having STEMI/cardiac arrest, TIMI 0/1 flow or proximal dissections.
Researchers reported procedural complications in 38.6% and serious complications in 13% of patients who had PCI. Those who experienced procedural complications demonstrated increases in extensive dissections (OR for multiple vs. single segments = 1.9; 95% CI, 1.06-3.39; P = .03), proximal dissections (OR per 1 mm = 2.25; 95% CI, 1.38-3.67; P = .001) and dissections with no contrast penetration of the false lumen (OR for Yip-Saw 2 vs. Yip-Saw 1= 2.89; 95% CI, 1.12-7.43; P = .028). Those who had PCI required a median stent length of 46 mm.
Despite the rise in complications, PCI for SCAD was associated with improvements in TIMI flow grade in 84.3% of patients, with 38.6% improving three grades, 23.6% improving two grades and 22.1% improving one grade. “Interestingly, these gains were mostly seen in cases where stenting, rather than more limited wiring or plain old balloon angioplasty strategies, was adopted,” Kotecha and colleagues wrote. They added that worsening TIMI flow only occurred in 7% of patients with SCAD who had PCI.
In longer-term data (median, 900 days), no significant differences were observed between groups in MACCE, revascularization, stroke, death and recurrent SCAD. Additionally, most patients retained good ejection fraction.
“While a conservative approach to revascularization in SCAD is optimal where possible, sometimes the clinical presentation (STEMI, cardiac arrest, poor TIMI flow and proximal occlusive dissection) mandates intervention to improve coronary perfusion and reduce myocardial injury,” the researchers wrote. “This study demonstrates that although more extensive stenting may be required, with an elevated risk of procedural complications, improved coronary flow and good medium-term outcomes can be achieved with PCI. More extensive dissection, proximal segment location and an absence of contrast penetration of the false lumen associate with the highest risk of PCI complications.”