Case report
Spontaneous left main dissection treated by percutaneous coronary intervention
Disseção do tronco comum tratada com intervenção coronária percutânea
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id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Tradução cintigráfica das alterações que ocorrem no SNS cardíaco no decurso da insuficiência cardíaca crónica<span class="elsevierStyleBold">.</span>NA: noradrenalina; MIBG: metaiodobenzilguanidina; SNS: sistema nervoso simpático; WR: <span class="elsevierStyleItalic">washout rate</span>.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Marta Inês Martins da Silva, Maria João Vidigal Ferreira, Ana Paula Morão Moreira" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Marta Inês" "apellidos" => "Martins da Silva" ] 1 => array:2 [ "nombre" => "Maria João" "apellidos" => "Vidigal Ferreira" ] 2 => array:2 [ "nombre" => "Ana Paula" "apellidos" => "Morão Moreira" ] ] ] ] ] "idiomaDefecto" => "pt" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2174204913001104" "doi" => "10.1016/j.repce.2013.06.006" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204913001104?idApp=UINPBA00004E" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255113000346?idApp=UINPBA00004E" "url" => "/08702551/0000003200000006/v2_201307110910/S0870255113000346/v2_201307110910/pt/main.assets" ] "en" => array:20 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>" "titulo" => "Spontaneous left main dissection treated by percutaneous coronary intervention" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "517" "paginaFinal" => "521" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Alexandra Sousa, Ricardo Lopes, João Carlos Silva, M. Júlia Maciel" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Alexandra" "apellidos" => "Sousa" "email" => array:1 [ 0 => "xanasousa81@gmail.com" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Ricardo" "apellidos" => "Lopes" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "João Carlos" "apellidos" => "Silva" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "M. Júlia" "apellidos" => "Maciel" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Cardiology Department, Centro Hospitalar São João, Porto, Portugal" "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Faculty of Medicine, Porto University, Porto, Portugal" "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Disseção do tronco comum tratada com intervenção coronária percutânea" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1590 "Ancho" => 1583 "Tamanyo" => 162978 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Coronary angiography showing an image suggestive of thrombus in the left main coronary artery (anteroposterior projection with caudal angulation).</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) is a rare cause of acute coronary events or sudden cardiac death.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> It often affects young women and usually involves a single coronary artery, mainly the left anterior descending (LAD) artery.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–4</span></a> SCAD has traditionally been observed in three groups of patients: those presenting with significant coronary atherosclerotic disease, women in the peripartum and early post-partum period or using oral contraceptives, and cases without obvious associated causal factors, termed idiopathic.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a> The clinical presentation is highly variable and depends on the location, extent and severity of SCAD.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Prognosis varies widely, but is generally dismal in the absence of prompt recognition and treatment, when the clinical presentation is sudden cardiac death, and in peripartum women.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,3</span></a> Treatment strategies include medical management, percutaneous coronary intervention (PCI) and surgical revascularization, the latter procedure being particularly indicated in cases of left main dissection, multivessel involvement and failed PCI procedures.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,7</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We report the case of a young woman who presented with SCAD of the left main and underwent successful PCI.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0015" class="elsevierStylePara elsevierViewall">A previously healthy 36-year-old woman presented to our institution, transferred from another center, with a diagnosis of non-ST elevation myocardial infarction, in cardiogenic shock (Killip class IV), for urgent coronary artery bypass graft (CABG) surgery. Her only cardiovascular risk factor was tobacco use and she had been on oral contraceptives for the last few years.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Previously that day, she had been admitted to another center for prolonged chest pain. Her physical examination was normal. The ECG demonstrated diffuse ST-segment depression, maximum 2 mm in V4-5 and I, and showed 1.5-mm ST-segment elevation in aVR. She was given 250 mg aspirin and 300 mg clopidogrel and treated with anti-ischemic drugs. Transthoracic echocardiogram (TTE) showed mild to moderate left ventricular (LV) systolic dysfunction, posterolateral akinesia, and moderate mitral regurgitation (MR) due to posterior leaflet restriction.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Due to recurrence of chest pain she underwent coronary angiography, which showed 50% distal left main coronary artery (LMCA) stenosis, 90% ostial LAD stenosis with an image suggestive of thrombus, occlusion of the left circumflex artery (LCx) at its origin and an angiographically normal right coronary artery. During catheterization, she became progressively unstable with severe hypotension and sustained chest pain. An intra-aortic balloon pump (IBP) was inserted and dopamine was initiated. The patient was transferred to our center for emergent CABG.</p><p id="par0030" class="elsevierStylePara elsevierViewall">On admission, the patient was in cardiogenic shock (BP 70/50 mmHg), despite IBP and vasopressor support (VPS), with sustained and severe chest pain. The ECG showed accentuation of the previous alterations (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">In view of the patient's unstable clinical condition, the need for immediate revascularization was balanced against the potential delay while awaiting preparation for bypass surgery. At a multidisciplinary meeting, it was therefore decided to attempt a percutaneous approach as first-line therapy.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The LMCA was engaged with a 7-Fr JL4 guiding catheter (Cordis Corp., Miami Lakes, FL) (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>; Video 1), and a 0.014-inch Runthrough guidewire (Terumo Medical Corp., Somerset, NJ) was passed to the distal LAD. An attempt was made to aspirate thrombotic material using an Export AP aspiration catheter (Medtronic Corp., Minneapolis), but with no success and no change in the angiographic appearance of the lesion. Neither the LCx nor its emergence from LMCA were visible, and we were unable to pass a guidewire through it. A more detailed evaluation of the lesions in several different projections showed an image suggestive of LMCA dissection (<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>A and B; Video 2A and B). Intravascular ultrasound was considered but was not used because of the patient's hemodynamic instability and the certainty of the diagnosis. Subsequently, the LMCA was predilated using a 3.0 mm × 15 mm balloon (TREK, Abbott Vascular, Abbott Park, IL) followed by the implantation of a drug-eluting stent (4.0 mm × 23 mm Xience Prime, Abbott Vascular, Abbott Park, IL), with a good angiographic result. After stenting, the LCx became visible and both the LAD and LCx presented no angiographic lesions (<a class="elsevierStyleCrossRef" href="#fig0020">Figure 4</a>A and B; Video 3A and B).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">The patient had a favorable evolution, with IBP and VPS withdrawn within 48 hours and with no complications. Her serum troponin I peaked at 43.2 ng/ml and TTE showed mild LV systolic dysfunction and mild to moderate MR. Given her positive clinical course, on day four she was transferred back to the original hospital.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0050" class="elsevierStylePara elsevierViewall">Spontaneous coronary artery dissection (SCAD) is a rare and under-recognized cause of acute coronary events or sudden cardiac death.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> Its incidence ranges from 0.07 to 1.1% in angiographic series.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2,4,8</span></a> It often affects young women,<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–4</span></a> with a mean age at presentation of 30–45 years; more than 70% of cases are women (approximately 30% in the peripartum period)<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a>.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Dissection of the LAD alone is most common (60–75% of cases),<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2,4–6,8</span></a> with multivessel and LMCA involvement in 20% and 12% of cases, respectively.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">SCAD has traditionally been observed in three groups of patients: those presenting with significant coronary atherosclerotic disease, women in the peripartum and early post-partum period, and patients without obvious associated causal factors, termed idiopathic.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a> SCAD has also been associated with various other conditions including connective tissue disorders, vasculitis, strenuous exercise, prolonged sneezing, use of cocaine, cyclosporine and, as in our case, oral contraceptives.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2,4–6</span></a> Although the precise etiology and pathogenesis of SCAD remain unclear, all these conditions are associated with weakening of connective tissue and/or vascular inflammation.</p><p id="par0065" class="elsevierStylePara elsevierViewall">The clinical profile of SCAD also varies according to gender, with women being characterized by more frequent involvement of the LAD, in the absence of coronary atherosclerosis and traditional cardiovascular risk factors, and an increased risk of occurrence during peripartum and under estrogen treatment. In men presentation occurs later in life, the right coronary artery is more often affected and there is often coexisting atherosclerotic coronary disease and cardiovascular risk factors.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,4</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">The clinical presentation is highly variable and depends on the location, extent and severity of SCAD.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The clinical spectrum includes unstable angina, acute myocardial infarction, heart failure, cardiogenic shock, cardiac tamponade, ventricular arrhythmias and sudden cardiac death.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,3</span></a> Rarely, it can be asymptomatic and an incidental finding on coronary angiography.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Treatment strategies include medical management, PCI and surgical revascularization, and the choice of initial management depends essentially on the location and extension of the dissection, its functional repercussions, and the patient's clinical status. If there is no evidence of ongoing ischemia or hemodynamic instability, in cases of single-vessel dissection not affecting the LMCA with TIMI 3 flow, SCAD can probably be managed successfully with a conservative approach.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,6,7,9,10</span></a> Medical management includes antithrombotic therapy with heparin or low molecular weight heparin, aspirin, clopidogrel and glycoprotein IIb/IIIa inhibitors, and anti-ischemic therapy with beta-blockers and nitrates. However, it should be borne in mind that while potent antithrombotic therapy decreases thrombus formation in the false lumen, enhancing blood flow in the true lumen, it can also increase bleeding into the false lumen, causing extension of the dissection. This is especially true for fibrinolytics and their use should generally be avoided.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,3,5</span></a> In single-vessel dissection not involving the LMCA, with persistent impairment of blood flow and signs of ongoing ischemia, PCI with stenting is the procedure of choice.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,6,7</span></a> Intravascular ultrasound and optical coherence tomography may be of value in identification of the true lumen, accurate guidewire placement and appropriate stent choice and deployment.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,11,12</span></a> The use of drug-eluting stents (DES) in SCAD is questionable. While the frequent need for long stented segments in these cases may justify the preferential use of DES, on the other hand, these stents may delay vessel wall healing. The choice between bare-metal stents and DES remains subject of disagreement.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,7</span></a> CABG is usually reserved for patients with LMCA dissection, multivessel involvement and failed PCI.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,7</span></a> Nevertheless, in selected cases LMCA and multivessel dissections may be treated by stenting as well,<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5–7</span></a> although this is not a common approach.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Prognosis varies widely, but is generally dismal in the absence of prompt recognition and treatment, when the clinical presentation is sudden cardiac death, and in peripartum women.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,3</span></a> In earlier studies, mortality was approximately 50%, with 50% recurrence at two months.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> In-hospital mortality is now relatively low, with a mean rate of 3%.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,7</span></a> Those who survive the acute phase have a good long-term prognosis, with very low recurrence of dissection and a long-term survival of over 95%,<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14,15</span></a> with the strongest predictors of death being female gender and absence of early treatment.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">The case reported was a typical SCAD patient – a young woman, under oral contraceptive therapy and a smoker. Even so, the definite diagnosis was not clear-cut. Percutaneous treatment of LMCA dissection has not often been reported in the literature (to our knowledge this is the fourth case described of left main stenting in a patient with SCAD<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,16</span></a>). In our case, given the rapid deterioration of the patient, with hemodynamic instability, a percutaneous approach seemed the most expeditious therapy.</p><p id="par0090" class="elsevierStylePara elsevierViewall">This case highlights the need to consider SCAD in the differential diagnosis of precordial pain in young women, especially in the peripartum period and in those using oral contraceptives, without classic cardiovascular risk factors. It should be borne in mind that differential diagnosis between thrombus and SCAD is not always straightforward on angiography, and visualization in different projections and complementary techniques, such as intravascular ultrasound and optical coherence tomography, are essential for correct diagnosis. In certain clinical scenarios, a percutaneous approach may be considered in spontaneous LMCA dissection.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Ethical disclosures</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Right to privacy and informed consent</span><p id="par0095" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Confidentiality of data</span><p id="par0100" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data and that all the patients included in the study received sufficient information and gave their written informed consent to participate in the study.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Protection of human and animal subjects</span><p id="par0105" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study.</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conflicts of interest</span><p id="par0110" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:2 [ "identificador" => "xres212839" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec199951" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres212840" "titulo" => "Resumo" ] 3 => array:2 [ "identificador" => "xpalclavsec199950" "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:3 [ "identificador" => "sec0020" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Right to privacy and informed consent" ] 1 => array:2 [ "identificador" => "sec0030" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0035" "titulo" => "Protection of human and animal subjects" ] ] ] 8 => array:2 [ "identificador" => "sec0040" "titulo" => "Conflicts of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2012-08-23" "fechaAceptado" => "2012-09-04" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec199951" "palabras" => array:4 [ 0 => "Acute coronary syndrome" 1 => "Cardiogenic shock" 2 => "Coronary angiography" 3 => "Stent" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec199950" "palabras" => array:4 [ 0 => "Síndroma coronária aguda" 1 => "Choque cardiogénico" 2 => "Angiografia coronária" 3 => "<span class="elsevierStyleItalic">Stent</span>" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Spontaneous coronary artery dissection is a rare cause of acute coronary events or sudden cardiac death. The clinical presentation is highly variable and prognosis varies widely, depending mainly on how rapidly it is diagnosed. Prompt treatment is also essential, and includes medical management, percutaneous coronary intervention and surgical revascularization.</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We describe the case of a young woman presenting with spontaneous coronary artery dissection of the left main coronary artery, first diagnosed as coronary thrombus, who underwent successful percutaneous coronary stenting. This report highlights the need to include spontaneous coronary artery dissection in differential diagnosis of chest pain in young women and that distinguishing between coronary thrombus and coronary artery dissection is not always straightforward. To our knowledge this is the fourth case of left main stenting in a patient with spontaneous coronary artery dissection described in the literature.</p>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">As disseções coronárias espontâneas são uma causa rara de eventos coronários agudos ou de morte súbita cardíaca. A sua apresentação clínica e prognóstico são altamente variáveis e dependem, principalmente, da rapidez com que o diagnóstico é feito. O tratamento imediato é também essencial, e inclui abordagem médica, intervenção coronária percutânea e revascularização cirúrgica.</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Descrevemos o caso de uma mulher jovem admitida com disseção espontânea do tronco comum da artéria coronária esquerda, primeiramente diagnosticada como trombo intracoronário. A paciente foi submetida a angioplastia percutânea mediante implantação de <span class="elsevierStyleItalic">stent</span>, com bom resultado angiográfico final. Este caso clínico enfatiza que a disseção coronária espontânea deve ser incluída no diagnóstico diferencial de dor torácica em mulheres jovens e, ainda, que a distinção entre trombo coronário e disseção coronária pode não ser simples. Este é o quarto caso de disseção do tronco comum tratado percutaneamente, mediante implantação de <span class="elsevierStyleItalic">stent</span>, que encontramos descrito na literatura.</p>" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0120" class="elsevierStylePara elsevierViewall">The following are the supplementary data to this article:<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 data" "identificador" => "sec0050" ] ] ] ] "multimedia" => array:9 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1628 "Ancho" => 3167 "Tamanyo" => 1135599 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Electrocardiogram at admission to our center.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1590 "Ancho" => 1583 "Tamanyo" => 162978 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Coronary angiography showing an image suggestive of thrombus in the left main coronary artery (anteroposterior projection with caudal angulation).</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1149 "Ancho" => 2333 "Tamanyo" => 192857 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Coronary angiography showing extensive left main coronary artery dissection. The left circumflex artery is not visualized. (A): Right anterior oblique with caudal angulation; (B): left anterior oblique with cranial angulation.</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1137 "Ancho" => 2333 "Tamanyo" => 182969 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Coronary angiography after left main coronary artery stenting. Both the left anterior descending artery and left circumflex artery are visualized and present no angiographic lesions. (A): Right anterior oblique with caudal angulation; (B): left lateral.</p>" ] ] 4 => array:7 [ "identificador" => "upi0005" "etiqueta" => "Movie 1" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc1.mpg" "ficheroTamanyo" => 1777664 "Video" => array:2 [ "flv" => array:5 [ "fichero" => "mmc1.flv" "poster" => "mmc1.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] "mp4" => array:2 [ "fichero" => "mmc1.m4v" "poster" => "mmc1.jpg" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Coronary angiography showing an image suggestive of thrombus in the left main coronary artery (anteroposterior projection with caudal angulation).</p>" ] ] 5 => array:7 [ "identificador" => "upi0010" "etiqueta" => "Movie 2" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc2.mpg" "ficheroTamanyo" => 2535424 "Video" => array:2 [ "flv" => array:5 [ "fichero" => "mmc2.flv" "poster" => "mmc2.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] "mp4" => array:2 [ "fichero" => "mmc2.m4v" "poster" => "mmc2.jpg" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Coronary angiography showing extensive left main coronary artery dissection. The left circumflex artery is not visualized. (A): Right anterior oblique with caudal angulation;(B): left anterior oblique with cranial angulation.</p>" ] ] 6 => array:5 [ "identificador" => "upi0015" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc3.mpg" "ficheroTamanyo" => 3078144 "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" ] ] ] ] 7 => array:7 [ "identificador" => "upi0020" "etiqueta" => "Movie 3" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc4.mpg" "ficheroTamanyo" => 2068480 "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" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Coronary angiography after left main coronary artery stenting. Both left anterior descending artery and left circumflex artery are visualized and present no angiographic lesions. 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| Ano/Mês | Html | Total | |
|---|---|---|---|
| 2024 Novembro | 10 | 10 | 20 |
| 2024 Outubro | 55 | 31 | 86 |
| 2024 Setembro | 63 | 30 | 93 |
| 2024 Agosto | 63 | 33 | 96 |
| 2024 Julho | 50 | 44 | 94 |
| 2024 Junho | 47 | 30 | 77 |
| 2024 Maio | 58 | 22 | 80 |
| 2024 Abril | 62 | 42 | 104 |
| 2024 Maro | 66 | 37 | 103 |
| 2024 Fevereiro | 52 | 33 | 85 |
| 2024 Janeiro | 42 | 29 | 71 |
| 2023 Dezembro | 40 | 39 | 79 |
| 2023 Novembro | 56 | 49 | 105 |
| 2023 Outubro | 31 | 14 | 45 |
| 2023 Setembro | 37 | 22 | 59 |
| 2023 Agosto | 30 | 17 | 47 |
| 2023 Julho | 37 | 18 | 55 |
| 2023 Junho | 36 | 12 | 48 |
| 2023 Maio | 63 | 31 | 94 |
| 2023 Abril | 42 | 12 | 54 |
| 2023 Maro | 47 | 27 | 74 |
| 2023 Fevereiro | 39 | 24 | 63 |
| 2023 Janeiro | 37 | 27 | 64 |
| 2022 Dezembro | 47 | 31 | 78 |
| 2022 Novembro | 75 | 29 | 104 |
| 2022 Outubro | 44 | 15 | 59 |
| 2022 Setembro | 47 | 46 | 93 |
| 2022 Agosto | 45 | 32 | 77 |
| 2022 Julho | 58 | 39 | 97 |
| 2022 Junho | 39 | 30 | 69 |
| 2022 Maio | 47 | 44 | 91 |
| 2022 Abril | 49 | 33 | 82 |
| 2022 Maro | 60 | 43 | 103 |
| 2022 Fevereiro | 41 | 26 | 67 |
| 2022 Janeiro | 65 | 30 | 95 |
| 2021 Dezembro | 37 | 42 | 79 |
| 2021 Novembro | 59 | 51 | 110 |
| 2021 Outubro | 61 | 34 | 95 |
| 2021 Setembro | 32 | 24 | 56 |
| 2021 Agosto | 54 | 34 | 88 |
| 2021 Julho | 29 | 23 | 52 |
| 2021 Junho | 43 | 22 | 65 |
| 2021 Maio | 63 | 39 | 102 |
| 2021 Abril | 61 | 49 | 110 |
| 2021 Maro | 84 | 18 | 102 |
| 2021 Fevereiro | 81 | 16 | 97 |
| 2021 Janeiro | 50 | 17 | 67 |
| 2020 Dezembro | 50 | 15 | 65 |
| 2020 Novembro | 55 | 18 | 73 |
| 2020 Outubro | 42 | 26 | 68 |
| 2020 Setembro | 77 | 10 | 87 |
| 2020 Agosto | 56 | 10 | 66 |
| 2020 Julho | 65 | 15 | 80 |
| 2020 Junho | 50 | 8 | 58 |
| 2020 Maio | 57 | 7 | 64 |
| 2020 Abril | 57 | 11 | 68 |
| 2020 Maro | 68 | 12 | 80 |
| 2020 Fevereiro | 109 | 16 | 125 |
| 2020 Janeiro | 39 | 21 | 60 |
| 2019 Dezembro | 48 | 15 | 63 |
| 2019 Novembro | 41 | 6 | 47 |
| 2019 Outubro | 37 | 5 | 42 |
| 2019 Setembro | 74 | 12 | 86 |
| 2019 Agosto | 45 | 4 | 49 |
| 2019 Julho | 47 | 11 | 58 |
| 2019 Junho | 48 | 14 | 62 |
| 2019 Maio | 85 | 29 | 114 |
| 2019 Abril | 54 | 31 | 85 |
| 2019 Maro | 51 | 24 | 75 |
| 2019 Fevereiro | 71 | 21 | 92 |
| 2019 Janeiro | 53 | 7 | 60 |
| 2018 Dezembro | 105 | 19 | 124 |
| 2018 Novembro | 183 | 12 | 195 |
| 2018 Outubro | 413 | 33 | 446 |
| 2018 Setembro | 130 | 13 | 143 |
| 2018 Agosto | 110 | 15 | 125 |
| 2018 Julho | 91 | 8 | 99 |
| 2018 Junho | 103 | 4 | 107 |
| 2018 Maio | 176 | 13 | 189 |
| 2018 Abril | 166 | 9 | 175 |
| 2018 Maro | 218 | 20 | 238 |
| 2018 Fevereiro | 113 | 6 | 119 |
| 2018 Janeiro | 129 | 5 | 134 |
| 2017 Dezembro | 228 | 19 | 247 |
| 2017 Novembro | 111 | 15 | 126 |
| 2017 Outubro | 81 | 16 | 97 |
| 2017 Setembro | 98 | 13 | 111 |
| 2017 Agosto | 103 | 18 | 121 |
| 2017 Julho | 94 | 13 | 107 |
| 2017 Junho | 110 | 27 | 137 |
| 2017 Maio | 83 | 6 | 89 |
| 2017 Abril | 72 | 3 | 75 |
| 2017 Maro | 107 | 8 | 115 |
| 2017 Fevereiro | 262 | 8 | 270 |
| 2017 Janeiro | 54 | 6 | 60 |
| 2016 Dezembro | 25 | 14 | 39 |
| 2016 Novembro | 95 | 18 | 113 |
| 2016 Outubro | 123 | 15 | 138 |
| 2016 Setembro | 153 | 7 | 160 |
| 2016 Agosto | 87 | 5 | 92 |
| 2016 Julho | 18 | 9 | 27 |
| 2016 Junho | 1 | 10 | 11 |
| 2016 Maio | 22 | 8 | 30 |
| 2016 Abril | 94 | 4 | 98 |
| 2016 Maro | 114 | 18 | 132 |
| 2016 Fevereiro | 100 | 27 | 127 |
| 2016 Janeiro | 81 | 20 | 101 |
| 2015 Dezembro | 95 | 17 | 112 |
| 2015 Novembro | 97 | 16 | 113 |
| 2015 Outubro | 116 | 19 | 135 |
| 2015 Setembro | 98 | 19 | 117 |
| 2015 Agosto | 103 | 10 | 113 |
| 2015 Julho | 167 | 11 | 178 |
| 2015 Junho | 83 | 7 | 90 |
| 2015 Maio | 71 | 6 | 77 |
| 2015 Abril | 120 | 10 | 130 |
| 2015 Maro | 115 | 5 | 120 |
| 2015 Fevereiro | 165 | 8 | 173 |
| 2015 Janeiro | 86 | 7 | 93 |
| 2014 Dezembro | 106 | 17 | 123 |
| 2014 Novembro | 95 | 9 | 104 |
| 2014 Outubro | 131 | 9 | 140 |
| 2014 Setembro | 129 | 15 | 144 |
| 2014 Agosto | 93 | 11 | 104 |
| 2014 Julho | 113 | 12 | 125 |
| 2014 Junho | 94 | 9 | 103 |
| 2014 Maio | 109 | 15 | 124 |
| 2014 Abril | 109 | 10 | 119 |
| 2014 Maro | 110 | 18 | 128 |
| 2014 Fevereiro | 128 | 19 | 147 |
| 2014 Janeiro | 123 | 18 | 141 |
| 2013 Dezembro | 96 | 15 | 111 |
| 2013 Novembro | 99 | 17 | 116 |
| 2013 Outubro | 98 | 16 | 114 |
| 2013 Setembro | 87 | 27 | 114 |
| 2013 Agosto | 97 | 44 | 141 |
| 2013 Julho | 98 | 43 | 141 |
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