Real-Time Intravascular Ultrasound-Guided Percutaneous Coronary Intervention for Spontaneous Coronary Artery Dissection

Figures

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  Figure 1. Admission 12-Lead Electrocardiogram Electrocardiogram showed sinus rhythm with subtle T-wave inversions in precordial leads V3 to V5.

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  Figure 2. Coronary Computed Tomography Angiography Coronary computed tomography angiography (CCTA) demonstrated severe luminal narrowing of a dominant proximal right coronary artery, suggestive of spontaneous coronary artery dissection (SCAD). The imaging features supporting SCAD rather than atherosclerotic narrowing include a smooth, tapered luminal narrowing without eccentric calcification or discrete atheromatous plaque and the complete absence of atheromatous disease elsewhere in the coronary tree.

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  Figure 3. Invasive Coronary Angiography Showing Normal Left Anterior Descending and Left Circumflex Arteries With No Atheroma Coronary angiography of the right coronary artery (RCA) demonstrates subtotal occlusion of the proximal RCA with TIMI flow grade 2, consistent with type 3 spontaneous coronary artery dissection. LCA = left coronary artery.

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  Figure 4. IVUS in the Conus Branch (A) Fluoroscopy showing intravascular ultrasound (IVUS) catheter advanced over a guidewire into the conus branch for imaging of the proximal right coronary artery (RCA) arrow). (B) Real-time IVUS from the conus branch provided a 360-degree cross-sectional view of the proximal RCA, demonstrating the true and false lumens (hematoma) of the spontaneous coronary artery dissection.

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  Figure 5. IVUS-Guided Wiring of Proximal RCA (A) Fluoroscopy demonstrating advancement of a second guidewire into the true lumen of the right coronary artery (RCA) under real-time intravascular ultrasound (IVUS) guidance from the conus branch, avoiding false lumen entry. (B) IVUS confirmed the guidewire position within the true lumen of the RCA. SCAD = spontaneous coronary artery dissection.

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  Figure 6. IVUS of RCA Intravascular ultrasound (IVUS) catheter was advanced over the right coronary artery (RCA) guidewire and confirmed true intraluminal wire position

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  Figure 7. Percutaneous Coronary Intervention of Spontaneous Coronary Artery Dissection (A) Deployment of a 3.5 × 24 mm drug-eluting stent covering the ostium of the right coronary artery (RCA) and post-dilation with a 3.5-mm noncompliant balloon. (B) Coronary angiography showed TIMI flow grade 3 in a dominant RCA. (C) Repeat intravascular ultrasound showed well-apposed stent and good stent expansion with a minimum stent area > 8 mm2 and no distal propagation of the hematoma

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  Visual Summary. Illustration of Real-Time IVUS-Guided Wiring Technique IVUS = intravascular ultrasound; RCA = right coronary artery.