Successful management of subacute stent mal-apposition confirmed using optical coherence tomography following cardiac arrest due to spontaneous coronary artery dissection in a middle-aged woman: a case report.

Abstract

Background: In patients with spontaneous coronary artery dissection (SCAD), percutaneous coronary intervention is considered only in a limited number of situations. There are a few reports on therapeutic interventions for SCAD in the acute phase, none on those performed during the subacute phase.

Case summary: A previously healthy 51-year-old woman was transported to our hospital, where ST elevation was noted on an electrocardiogram in the emergency room. Subsequently, she experienced ventricular fibrillation and cardiac arrest. Extracorporeal membrane oxygenation was initiated; coronary angiography (CAG) revealed severe right coronary artery stenosis. Intramural haematoma on intravascular ultrasonography led to SCAD diagnosis. Despite continued electrical defibrillation after extracorporeal membrane oxygenation initiation, the ventricular fibrillation persisted. However, after relieving ischaemia in the right coronary artery territory via stent placement, the ventricular fibrillation ceased. She developed a cerebral haemorrhage; from days 8 to 36, dual antiplatelet therapy (DAPT) had to be completely discontinued. On hospital day 56, although CAG detected no significant stenosis, optical coherence tomography (OCT) revealed marked stent mal-apposition. Additional dilation was performed using a non-compliant balloon. On follow-up OCT on day 196, most of the struts were covered by the intima. She received DAPT for 1 year, then switched to single antiplatelet therapy and remained free of cardiovascular events for 3 years.

Discussion: Although no recommended treatments for mal-apposition following stenting for SCAD currently exist, dilation in the subacute phase may lead to a favourable outcome. This approach warrants consideration as a future therapeutic option for SCAD.