Spontaneous Coronary Artery Dissection Involving the Left Main with Extension to Left Anterior Descending Artery and Left Circumflex Artery: Diagnostic and Management Challenges

Figure 1. The ECG of a 43-year-old female patient presenting to the Emergency Department (ED) with recurrent retrosternal chest pain at rest, radiating to the back, lasting approximately 10 min, with no significant ST-T changes on the electrocardiogram. The physical exam did not reveal any pathological signs; blood pressure was 120/60 mmHg bilaterally, and heart rate was 60 beats per minute. Echocardiography revealed akinesia of one-third of the anterior, inferior, and lateral walls and septum, with an estimated ejection fraction of 45%. No pericardial effusion was noted, and the aorta had normal dimensions and no intimal flap. Serological results showed normal cardiac necrosis markers. Of note, the patient denied significant medical family history. She was being treated for chronic anxiety.

Figure 2. Seeing as the patient had a low suspicion for atherosclerotic disease, we first performed a CT coronary angiography (CTCA), which revealed a significant stenosis of the left anterior descending artery (LAD) (blue arrow); Ao = aorta.

Figure 3. The patient later experienced another episode of resting chest pain. An ECG performed at that time revealed deep, diffuse negative T waves in V1–V6, DI, DII, aVL, and aVF.

Figure 4. Subsequent ECGs demonstrated the evolution of the ST-T segment, consistent with a Wellens syndrome pattern. Cardiac necrosis markers increased.

Figure 5. We performed urgent coronarography, which, surprisingly, revealed mild, smooth stenoses in the proximal segments of the LAD and Cx coronary arteries (solid arrows) along with distal stenoses in the mid-LAD and diagonal branch (dashed arrows).

Figure 6. Given the striking discrepancies between the patient’s symptoms, ECG, and CTCA results, we decided to investigate further, and an intravascular ultrasound (IVUS) was performed. It revealed spontaneous coronary artery dissection (SCAD) in the distal left main artery, with extensions in the LAD and proximal circumflex arteries, with hematomas present, classified as a type 2a (Figure 6—spontaneous coronary artery dissections shown by blue arrows; Cx emergence from LMCA—yellow arrow; there is non-significant plaque on LMCA; grey arrow was generated by IVUS and represents a probe marker). The lesions in mid-LAD and the diagonal branch were focal dissections. Given that the hematomas were most likely favored by parenteral anticoagulation, we withdrew this medication, maintaining dual antiplatelet therapy with aspirin and clopidogrel. Conservative management was chosen for this patient because she was hemodynamically stable, angina-free, with normal coronary flow, and without significant atherosclerotic stenoses at the moment of coronarography. We considered that angioplasty with stent implantation had a higher risk due to fragile coronary vessels. The potential benefit of stent…