Case report
Spontaneous coronary artery dissection: Still a lot to learn
Disseção coronária espontânea – ainda muito por aprender
David Neves
, Ângela Bento, Renato Fernandes, Lino Patrício, José Aguiar
Corresponding author
Serviço de Cardiologia, Hospital Espírito Santo, Évora, Portugal
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=> array:2 [ "en" => true "pt" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1175 "Ancho" => 1801 "Tamanyo" => 332061 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Coronary angiography showing (A) 85% long stenosis of the first obtuse marginal branch and 80% stenosis of the distal circumflex (CX) artery (arrows); (B) these lesions treated with two and one drug-eluting stents (DES), respectively; (C) the CX with gadolinium contrast after six months; (D) early right coronary artery (RCA) bifurcation, 90% stenosis of the right posterolateral branch (RPL) (arrows), 90% at the origin of the posterior interventricular artery (PIA) and 80% distal to the PIA; (E) these lesions treated with two DES in the RPL, one DES at the origin of the PIA and another in the distal segment of the PIA; (F) coronary angiography of the RCA with gadolinium contrast after six months. 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array:1 [ "total" => 0 ] "idiomaDefecto" => "pt" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255116302207?idApp=UINPBA00004E" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204916302288?idApp=UINPBA00004E" "url" => "/21742049/0000003600000001/v1_201701200114/S2174204916302288/v1_201701200114/en/main.assets" ] "en" => array:20 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>" "titulo" => "Spontaneous coronary artery dissection: Still a lot to learn" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "59.e1" "paginaFinal" => "59.e5" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "David Neves, Ângela Bento, Renato Fernandes, Lino Patrício, José Aguiar" "autores" => array:5 [ 0 => array:4 [ "nombre" => "David" "apellidos" => "Neves" "email" => array:1 [ 0 => "dcneves25@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Ângela" "apellidos" => "Bento" ] 2 => array:2 [ "nombre" => "Renato" "apellidos" => "Fernandes" ] 3 => array:2 [ "nombre" => "Lino" "apellidos" => "Patrício" ] 4 => array:2 [ "nombre" => "José" "apellidos" => "Aguiar" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Serviço de Cardiologia, Hospital Espírito Santo, Évora, Portugal" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Disseção coronária espontânea – ainda muito por aprender" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1159 "Ancho" => 1501 "Tamanyo" => 220447 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Distal right coronary artery (RCA) viewed by optical coherence tomography (OCT). Location of the OCT frame within the RCA is easily identified on the angiogram (arrow). Although the angiogram projection eventually captured the vessel at its smallest diameter (red line), this should be 4.03 mm as measured by OCT. By angiography the largest diameter of the segment is 2.1 mm. This suggests that the false lumen (F) is filled with a clear fluid, but not contrast, since on the angiogram only the true lumen (T) is visible, corresponding to the 2.07 mm mean true luminal diameter measured by OCT. Moreover, on OCT the catheter can be seen at the center of the vessel, but touching the intimal wall, while on the angiogram it appears adjacent to the wall, suggesting that only the true lumen is visible.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Spontaneous coronary artery dissection (SCAD) has long been known to the scientific community – at least since the first case description in 1931.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">1</span></a> It is thought to be relatively rare – about 3% of acute coronary syndromes (ACS)<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">2</span></a> – but important, since it can have significant consequences such as ischemia, ACS, malignant arrhythmias and sudden cardiac death.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">3</span></a> It may also present with mild and/or atypical symptoms or even be asymptomatic, and can therefore be under-diagnosed. It can also lead to transient wall motion abnormalities and be misdiagnosed as Takotsubo cardiomyopathy.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The pathophysiology of this entity is not completely understood. Mechanistically, it has been proposed that an intramural hematoma forms due to one of two mechanisms: an intimal tear or intramural hemorrhage from the vasa vasorum.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">5</span></a> There is often an underlying arteriopathy and a precipitating stressful event, like intense exercise. The arteriopathy may be due to atherosclerosis, peripartum state, connective tissue disorders, systemic inflammatory conditions, coronary artery spasm or other conditions.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">6</span></a> It has also been associated with fibromuscular dysplasia in non-coronary arteries.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">7</span></a> Intravascular imaging has a crucial role in the study and management of this condition, especially optical coherence tomography (OCT), due to its very high spatial resolution.<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">8–10</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">After diagnosis, long-term prognosis is usually benign.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">11</span></a> We report on a clinically challenging case in which a spontaneous dissection was diagnosed.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0020" class="elsevierStylePara elsevierViewall">We report the case of a 50-year-old woman with no known cardiovascular risk factors and a history of thyroid disease and anemia during adolescence that eventually resolved without a specific diagnosis. She was diagnosed with probable myocardial infarction with normal coronary arteries three years before this event. At that time she had a coronary angiogram, which revealed no angiographically significant coronary artery disease (Video 1). She also underwent a myocardial perfusion scan, which was normal, and cardiac magnetic resonance imaging (MRI), which showed a localized transmural scar in the medial segment of the anterior wall (Online Figure 1). She was discharged on dual antiplatelet therapy for one year, followed by monotherapy with aspirin, as well as a statin, angiotensin-converting enzyme inhibitor and beta-blocker. In May 2015, just starting menopause, and in the context of severe emotional stress, she presented with severe central chest pain radiating to the back and neck, which resolved in 30 min after taking sublingual nitroglycerin. The next day the pain recurred, with greater intensity, sharper (not clearly oppressive) and radiating to both arms, with no relieving factors. She contacted the emergency services and was transported to hospital.</p><p id="par0025" class="elsevierStylePara elsevierViewall">On admission the pain was decreasing; the physical examination was unremarkable, the electrocardiogram showed sinus rhythm, with negative T waves in the inferior leads, and troponin I was positive. The pain eventually disappeared after intravenous nitrates, and she was admitted to the coronary care unit. She underwent coronary angiography (<a class="elsevierStyleCrossRef" href="#fig0015">Figure 1</a>, Video 2), which revealed a spontaneous dissection of the posterior descending artery, with TIMI 2 flow, some posterolateral branches visualized from intercoronary collaterals, and severe vasospasm of the proximal right coronary artery (RCA), which reproduced the pain, relieved after intracoronary nitrates. No other unequivocal coronary lesions were noted, although a long dissection of the left anterior descending artery with intact intima cannot be excluded (Online Figure 2). It was decided not to perform percutaneous coronary intervention (PCI), and she was kept in the ward anticoagulated with subcutaneous enoxaparin (1 mg/kg twice daily), with dual antiplatelet therapy and a calcium channel blocker. Screening for autoimmune disease was negative. There were no events during hospitalization and she was scheduled for an angiographic review a week later, which showed progression of the dissection, with a wider false lumen (<a class="elsevierStyleCrossRef" href="#fig0020">Figure 2</a>, Video 3). Pain recurred during the procedure and a dissection was noted in a posterolateral branch. It was decided to perform PCI, and two bioabsorbable vascular scaffolds (BVS) were implanted in the PDA, guided by optical coherence tomography (OCT) coregistered with angiography. A third BVS was implanted in the distal RCA due to proximal progression of the dissection. A bare-metal stent was also implanted in the ostial RCA due to a traumatic dissection induced by the guiding catheter. Comparison of the images from angiography and OCT reveals a discrepancy in total (false plus true) diameter in the distal RCA (<a class="elsevierStyleCrossRef" href="#fig0025">Figure 3</a>, Video 4). After the procedure the patient was asymptomatic, although with a significant residual dissection in the RCA and posterolateral branch (Video 5). Anticoagulation was suspended and she was discharged five days later, with no further episodes of chest pain. Four months after this episode, she has had no recurrence of pain and is asymptomatic.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0030" class="elsevierStylePara elsevierViewall">This case illustrates several important features of SCAD. Firstly, clinical context: a young woman without cardiovascular risk factors – SCAD may be present in as many as 24% of women aged over 50 with myocardial infarction.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">12</span></a> Secondly, the characteristics of this condition are often elusive, like the often atypical pain (described as “sharp” in this patient). Since she was in the perimenopausal period, hormonal variations may have played a role in this case, possibly similarly to pregnancy-related SCAD.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The first event, three years previously, may also have been a case of dissection, although an intimal flap or intramural hematoma was not visible on careful examination of the images. SCAD may be difficult to diagnose by angiography alone, and can frequently mimic atherosclerosis. A diagnostic algorithm and angiographic classification of SCAD into three types has recently been proposed.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">13</span></a> Intracoronary imaging has a growing role in diagnosing and understanding this condition.</p><p id="par0040" class="elsevierStylePara elsevierViewall">In the recent event, the dissection was evident on angiography, and a conservative approach was adopted, as is common in such cases, with reported good results.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">14</span></a> The patient was on anticoagulants with the purpose of promoting patency of the true lumen, as is the practice in other centers, with good results.<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">15</span></a> Despite the patient's clinical stability with absence of pain, in the second procedure an aggravation of the dissection was noted, with progression in length and width of the false lumen. There are no specific recommendations on antithrombotic treatment in these cases and there is some controversy in balancing the risks of true lumen patency and false lumen progression.<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">16</span></a> In this case anticoagulation may have had a deleterious effect on intimal stabilization.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Although asymptomatic, the noticeable progression of the dissection prompted treatment with stent implantation. There is little evidence on the use of BVS for the treatment of SCAD, but bearing in mind the young age of the patient, the soft-walled vessel without calcium and the low radial strength required, it appeared to be an interesting option. The dissection progressed, requiring a new stent, as is often the case. It has been reported that about 25% of cases of successful PCI in SCAD require the placement of ≥2 further stents due to propagation of the dissection.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">17</span></a> We believe the traumatic dissection of the ostium is evidence of the frailty of the whole vessel intima, since no aggressive cannulation was performed.</p><p id="par0050" class="elsevierStylePara elsevierViewall">The discrepancy in lumen diameter during coregistration is an intriguing feature in this case, which could easily be attributed to technical inaccuracy. In fact, a blood-filled false lumen gradually being filled with contrast is the most likely explanation for this finding. However, unlike blood, which has high backscatter and variable attenuation, a uniform and completely black structure on OCT must represent a transparent fluid-filled structure, which is usually contrast. OCT in this case shows a very large total diameter vessel (4.19 mm in <a class="elsevierStyleCrossRef" href="#fig0025">Figure 3</a>) and suggests the false lumen was filled not with blood, but with a clear fluid which angiography indicated was not contrast, since it corresponds to a small diameter vessel (with contrast only in the true lumen – red arrow in <a class="elsevierStyleCrossRef" href="#fig0025">Figure 3</a>). Because a false lumen may require several contrast injections until it is completely opacified, especially if it is long and with a small entry point, comparison of OCT and angiography pictures taken after consecutive injections may be misleading, since the contrast content of the false lumen may be different. The coregistration applied in this case is essential in this regard, since it gives real-time coordinated comparison of the images. To our knowledge, a vessel wall effusion with clear fluid has never been reported in the pathophysiology of SCAD, so the explanation for this finding remains debatable, as it is difficult to interpret.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusions</span><p id="par0055" class="elsevierStylePara elsevierViewall">SCAD is a differential diagnosis that should be borne in mind in cases of ACS, especially in young women without cardiovascular risk factors.</p><p id="par0060" class="elsevierStylePara elsevierViewall">An initially conservative approach should always be considered in SCAD, and anticoagulation may not be of benefit in all cases.</p><p id="par0065" class="elsevierStylePara elsevierViewall">The pathophysiology of SCAD is not fully understood. Effusion of fluid other than blood could play a part in its development prior to intimal tear or intramural hematoma.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Ethical disclosures</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Protection of human and animal subjects</span><p id="par0070" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Confidentiality of data</span><p id="par0075" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Right to privacy and informed consent</span><p id="par0080" class="elsevierStylePara elsevierViewall">The authors have obtained the written informed consent of the patients or subjects mentioned in the article. The corresponding author is in possession of this document.</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Conflicts of interest</span><p id="par0085" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres792072" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec790468" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres792073" "titulo" => "Resumo" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec790469" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conclusions" ] 8 => array:3 [ "identificador" => "sec0025" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0030" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0035" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0040" "titulo" => "Right to privacy and informed consent" ] ] ] 9 => array:2 [ "identificador" => "sec0045" "titulo" => "Conflicts of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-11-06" "fechaAceptado" => "2016-06-04" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec790468" "palabras" => array:3 [ 0 => "Spontaneous coronary artery dissection" 1 => "Optical coherence tomography" 2 => "Percutaneous coronary intervention" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec790469" "palabras" => array:3 [ 0 => "Disseção coronária espontânea" 1 => "Tomografia de coerência óptica" 2 => "Angioplastia coronária" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Non-atherosclerotic spontaneous coronary artery dissection (SCAD) is an uncommon but probably underdetected pathological substrate for acute coronary syndrome. Clinical associations have been noted, like female gender and young age, but its pathophysiology is not yet fully understood. In this report we describe the case of a 50-year-old woman, without cardiovascular risk factors presenting with non-ST segment elevation myocardial infarction, in whom SCAD was diagnosed. Treatment was initially conservative but due to aggravation of the dissection she eventually underwent a complex percutaneous coronary intervention, requiring implantation of multiple stents, but with a good clinical outcome. The procedure was guided by optical coherence tomography (OCT). Carefully analyzing the combined pictures of OCT and angiography, the dissection appeared to be filled with a clear fluid, but not contrast.</p></span>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A disseção espontânea de artéria coronária (DEAC) é uma causa pouco frequente, mas provavelmente sub-diagnosticada, de síndrome coronária aguda. Estão descritas algumas associações clínicas, como o sexo feminino e a idade jovem, mas ainda não está estabelecida a completa fisiopatologia desta entidade. Neste trabalho apresentamos o caso de uma mulher de 50 anos, sem fatores de risco conhecidos, que se apresenta com um enfarte agudo do miocárdio sem supra-desnivelamento de ST, e em quem é diagnosticada uma DEAC. O tratamento foi inicialmente conservador, no entanto, devido a agravamento da disseção, acabou por realizar uma angioplastia complexa, requerendo implantação de vários <span class="elsevierStyleItalic">stents</span>, com bom resultado clínico. O procedimento foi guiado com tomografia de coerência óptica (OCT). Na análise cuidada das imagens de OCT e angiografia, constata-se que a disseção aparenta estar preenchida com um fluido translúcido, mas não contraste.</p></span>" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0095" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="upi0005"></elsevierMultimedia><elsevierMultimedia ident="upi0010"></elsevierMultimedia><elsevierMultimedia ident="upi0015"></elsevierMultimedia><elsevierMultimedia ident="upi0020"></elsevierMultimedia><elsevierMultimedia ident="upi0025"></elsevierMultimedia></p>" "etiqueta" => "Appendix A" "titulo" => "Supplementary material" "identificador" => "sec0055" ] ] ] ] "multimedia" => array:10 [ 0 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 850 "Ancho" => 910 "Tamanyo" => 128814 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">First angiogram of the right coronary artery (RCA), showing a long spontaneous coronary artery dissection from the distal RCA to the distal posterior descending artery and posterolateral branches.</p>" ] ] 1 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 853 "Ancho" => 911 "Tamanyo" => 122205 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Second angiogram of the right coronary artery, showing a wider false lumen in the posterior descending artery, greater true lumen compromise and worse flow to the posterolateral branches.</p>" ] ] 2 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1159 "Ancho" => 1501 "Tamanyo" => 220447 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Distal right coronary artery (RCA) viewed by optical coherence tomography (OCT). Location of the OCT frame within the RCA is easily identified on the angiogram (arrow). Although the angiogram projection eventually captured the vessel at its smallest diameter (red line), this should be 4.03 mm as measured by OCT. By angiography the largest diameter of the segment is 2.1 mm. This suggests that the false lumen (F) is filled with a clear fluid, but not contrast, since on the angiogram only the true lumen (T) is visible, corresponding to the 2.07 mm mean true luminal diameter measured by OCT. Moreover, on OCT the catheter can be seen at the center of the vessel, but touching the intimal wall, while on the angiogram it appears adjacent to the wall, suggesting that only the true lumen is visible.</p>" ] ] 3 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc3.mp4" "ficheroTamanyo" => 246828 "Video" => array:2 [ "flv" => array:5 [ "fichero" => "mmc3.flv" "poster" => "mmc3.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] "mp4" => array:2 [ "fichero" => "mmc3.m4v" "poster" => "mmc3.jpg" ] ] ] ] 4 => array:5 [ "identificador" => "upi0010" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc4.mp4" "ficheroTamanyo" => 296800 "Video" => array:2 [ "flv" => array:5 [ "fichero" => "mmc4.flv" "poster" => "mmc4.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] "mp4" => array:2 [ "fichero" => "mmc4.m4v" "poster" => "mmc4.jpg" ] ] ] ] 5 => array:5 [ "identificador" => "upi0015" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc5.mp4" "ficheroTamanyo" => 337940 "Video" => array:2 [ "flv" => array:5 [ "fichero" => "mmc5.flv" "poster" => "mmc5.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] "mp4" => array:2 [ "fichero" => "mmc5.m4v" "poster" => "mmc5.jpg" ] ] ] ] 6 => array:5 [ "identificador" => "upi0020" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc6.mp4" "ficheroTamanyo" => 3451872 "Video" => array:2 [ "flv" => array:5 [ "fichero" => "mmc6.flv" "poster" => "mmc6.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] "mp4" => array:2 [ "fichero" => "mmc6.m4v" "poster" => "mmc6.jpg" ] ] ] ] 7 => array:5 [ "identificador" => "upi0025" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc7.mp4" "ficheroTamanyo" => 257624 "Video" => array:2 [ "flv" => array:5 [ "fichero" => "mmc7.flv" "poster" => "mmc7.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] "mp4" => array:2 [ "fichero" => "mmc7.m4v" "poster" => "mmc7.jpg" ] ] ] ] 8 => array:6 [ "identificador" => "fig0005" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "mmc1.jpeg" "Alto" => 780 "Ancho" => 909 "Tamanyo" => 73542 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleBold">Online Figure 1</span> 2-chamber view of the left ventricle by magnetic resonance imaging, showing transmural late gadolinium enhancement, suggestive of a localized anterior myocardial infarction.</p>" ] ] 9 => array:6 [ "identificador" => "fig0010" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "mmc2.jpeg" "Alto" => 855 "Ancho" => 909 "Tamanyo" => 127943 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleBold">Online Figure 2</span> Left coronary angiography. A long dissection of the left anterior descending artery with intact intima cannot be excluded. It was decided not to perform optical coherence tomography due to the high procedural risk.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:17 [ 0 => array:3 [ "identificador" => "bib0090" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Dissecting aneurysms of coronary artery in woman aged 42: rupture" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "H. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 4 | 4 | 8 |
| 2024 October | 42 | 35 | 77 |
| 2024 September | 53 | 36 | 89 |
| 2024 August | 49 | 24 | 73 |
| 2024 July | 36 | 34 | 70 |
| 2024 June | 32 | 19 | 51 |
| 2024 May | 40 | 18 | 58 |
| 2024 April | 44 | 32 | 76 |
| 2024 March | 46 | 18 | 64 |
| 2024 February | 26 | 28 | 54 |
| 2024 January | 28 | 29 | 57 |
| 2023 December | 40 | 34 | 74 |
| 2023 November | 38 | 22 | 60 |
| 2023 October | 26 | 19 | 45 |
| 2023 September | 33 | 30 | 63 |
| 2023 August | 34 | 24 | 58 |
| 2023 July | 43 | 7 | 50 |
| 2023 June | 34 | 15 | 49 |
| 2023 May | 52 | 24 | 76 |
| 2023 April | 32 | 8 | 40 |
| 2023 March | 61 | 20 | 81 |
| 2023 February | 51 | 24 | 75 |
| 2023 January | 38 | 26 | 64 |
| 2022 December | 62 | 27 | 89 |
| 2022 November | 62 | 32 | 94 |
| 2022 October | 35 | 22 | 57 |
| 2022 September | 46 | 35 | 81 |
| 2022 August | 40 | 39 | 79 |
| 2022 July | 41 | 45 | 86 |
| 2022 June | 47 | 33 | 80 |
| 2022 May | 37 | 31 | 68 |
| 2022 April | 36 | 23 | 59 |
| 2022 March | 43 | 44 | 87 |
| 2022 February | 31 | 30 | 61 |
| 2022 January | 67 | 26 | 93 |
| 2021 December | 29 | 38 | 67 |
| 2021 November | 79 | 37 | 116 |
| 2021 October | 49 | 41 | 90 |
| 2021 September | 32 | 27 | 59 |
| 2021 August | 36 | 25 | 61 |
| 2021 July | 21 | 29 | 50 |
| 2021 June | 25 | 19 | 44 |
| 2021 May | 41 | 34 | 75 |
| 2021 April | 73 | 36 | 109 |
| 2021 March | 52 | 14 | 66 |
| 2021 February | 71 | 30 | 101 |
| 2021 January | 32 | 13 | 45 |
| 2020 December | 42 | 7 | 49 |
| 2020 November | 46 | 25 | 71 |
| 2020 October | 53 | 15 | 68 |
| 2020 September | 51 | 13 | 64 |
| 2020 August | 23 | 11 | 34 |
| 2020 July | 63 | 3 | 66 |
| 2020 June | 43 | 23 | 66 |
| 2020 May | 52 | 10 | 62 |
| 2020 April | 51 | 9 | 60 |
| 2020 March | 42 | 18 | 60 |
| 2020 February | 145 | 44 | 189 |
| 2020 January | 43 | 9 | 52 |
| 2019 December | 32 | 4 | 36 |
| 2019 November | 29 | 11 | 40 |
| 2019 October | 27 | 7 | 34 |
| 2019 September | 29 | 8 | 37 |
| 2019 August | 30 | 4 | 34 |
| 2019 July | 28 | 12 | 40 |
| 2019 June | 29 | 11 | 40 |
| 2019 May | 34 | 8 | 42 |
| 2019 April | 31 | 21 | 52 |
| 2019 March | 101 | 7 | 108 |
| 2019 February | 70 | 11 | 81 |
| 2019 January | 57 | 6 | 63 |
| 2018 December | 93 | 14 | 107 |
| 2018 November | 104 | 8 | 112 |
| 2018 October | 156 | 19 | 175 |
| 2018 September | 61 | 9 | 70 |
| 2018 August | 38 | 3 | 41 |
| 2018 July | 26 | 4 | 30 |
| 2018 June | 59 | 8 | 67 |
| 2018 May | 68 | 13 | 81 |
| 2018 April | 88 | 7 | 95 |
| 2018 March | 112 | 7 | 119 |
| 2018 February | 34 | 3 | 37 |
| 2018 January | 74 | 8 | 82 |
| 2017 December | 110 | 5 | 115 |
| 2017 November | 45 | 14 | 59 |
| 2017 October | 29 | 8 | 37 |
| 2017 September | 17 | 6 | 23 |
| 2017 August | 21 | 8 | 29 |
| 2017 July | 13 | 11 | 24 |
| 2017 June | 34 | 23 | 57 |
| 2017 May | 36 | 19 | 55 |
| 2017 April | 24 | 20 | 44 |
| 2017 March | 37 | 29 | 66 |
| 2017 February | 57 | 34 | 91 |
| 2017 January | 29 | 17 | 46 |
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