Spontaneous multivessel coronary artery dissection in a female without connective tissue disease: An acute myocardial infarction in a young patient

Fig. 1. Initial invasive coronary angiography. (A) First diagnostic coronary angiogram of the RCA performed using a 5Fr Judkins right catheter, showing contrast flow into the RCA. (B and C) highlighting the linear radiolucency within the RCA lumen (white arrows) indicative of an intimal flap—a hallmark of coronary artery dissection. (D) A possible linear radiolucency along the LAD artery (red arrow) suggesting an additional dissection, not initially identified during the initial procedure. RCA, right coronary artery; LAD, left anterior descending.

Fig. 2. Immediate percutaneous coronary intervention for catheter-induced dissection. Angiographic image showed immediate percutaneous coronary intervention (PCI) of the right coronary artery (RCA) following identification of iatrogenic dissection. Overlapping Onyx Frontier drug-eluting stents (3.0 × 38 mm, 3.0 × 38 mm and 3.5 × 15 mm) were deployed to 12 atmospheres from distal to ostial RCA. Poststenting showed angiography demonstrated restored vessel patency. RCA, right coronary artery.

Fig. 3. Follow-up invasive coronary angiography demonstrating stent patency. Re-look invasive coronary angiography 6 days post-stenting later showed improved angiographic appearance of the previously-stented RCA. RCA, right coronary artery.

Fig. 4. Intravascular ultrasound (IVUS) evaluation 6 days post-percutaneous coronary intervention. IVUS imaging was performed to access stent apposition and vessel wall integrity. (A and B) Cross sectional IVUS images reveal an echo-free space (white asterisks), indicative of a false lumen caused by dissection. (C) A segment with mixed echogenic stagnant blood (red arrow), confirmed intramural haematoma. Additionally, minor stent malapposition is noted in the mid-vessel (A and B) which was addressed with a 3.25 mm noncompliant (NC) balloon inflated to 14 atmospheres, improving stent expansion and wall apposition.

Fig. 5. Diagnostic coronary angiography (third procedure). (A) Repeat coronary angiogram demonstrated a stable appearance of previously stented RCA. (B and C) Nonselective contrast injection showed a dissection flap in LCx artery (red arrows); visible as a linear radiolucency and severe narrowing of proximal LAD artery. RCA, right coronary artery; LCx, left circumflex; LAD, left anterior descending.

Fig. 6. CT coronary angiography demonstrating LAD dissection with thrombosed false lumen. (A) Unenhanced low-dose CT scan performed for coronary calcium scoring revealed high attenuation within the proximal LAD coronary artery wall, suggesting an intramural thrombus (white arrow). (B) Contrast-enhanced CT coronary angiogram shows soft tissue density within the wall of the proximal LAD with luminal narrowing, suggestive of coronary dissection and a thrombosed false lumen (dashed arrow). CT, computed tomography; LAD, left anterior descending.

Fig. 7. Multimodality follow-up demonstrating LAD dissection and spontaneous healing. (A) CMR with cross-sectional views of the proximal LAD coronary artery revealed severe stenosis of the contrast-opacified true lumen of proximal LAD (arrowheads). (B) Follow-up CT coronary angiogram with CMR after 50 days revealed significant interval improvement in luminal patency of the left proximal LAD (arrowheads) and resolution of the previously identified thrombosed false lumen. These findings indicate progressive vessel wall healing and patency without further invasive intervention. CMR, curved multiplanar reformats; CT, computed tomography; LAD, left anterior descending.