An in-depth analysis of coronary computed tomography angiography segmental findings in acute spontaneous coronary artery dissection – a prospective multicenter study

Spontaneous coronary artery dissection (SCAD), causing acute coronary syndrome (ACS), primarily in middle-aged women, is diagnosed with invasive coronary angiography (ICA). Due to the risk of dissection propagation with ICA, a non-invasive diagnostic tool is needed. We investigated coronary computed tomography angiography (CCTA) findings in acute SCAD, as well as the inter-modality agreement between CCTA and ICA. Thirty-two (92 ​% women, mean age 52.4 years) SCAD patients at eight Swedish hospitals were investigated with ICA as well as dual source CCTA during the index hospitalisation between April 2021 and October 2022. ICA identified 46 dissected segments whereas CCTA detected 25, Cohen's kappa (κ) ​= ​0.595 (95 ​% confidence interval [CI] 0.46-0.73). CCTA primary and secondary features were identified in 24 dissected coronary artery segments in 21 patients, 8 (32 ​%) tapered luminal stenosis, 11 (44 ​%) abrupt luminal stenosis, 3 (12 ​%) visible dissection membrane, 4 (16 ​%) intramural-hematomas, 9 (36 ​%) epicardial fat stranding and 8 (25 ​%) with coronary artery tortuosity. ICA identified 3 dissected proximal segments whereas CCTA identified 5, (κ ​= ​0.74, 95 ​% CI 0.40-1.00). In distal segments, ICA identified 43 and CCTA 20 dissections, (κ ​= ​0.57, 95 ​% CI 0.43-0.72). In patients presenting with acute SCAD, CCTA should not be considered a substitute for ICA. While CCTA demonstrated good diagnostic performance in identifying proximal SCAD lesions, its sensitivity was notably reduced in distal coronary segments, where SCAD is more frequent. Among the 25 lesions detected, CCTA successfully detected specific features in 24 lesions.