A contemporary algorithm to guide percutaneous coronary intervention in high-risk spontaneous coronary artery dissection.

Spontaneous coronary artery dissection (SCAD) is increasingly recognized as a cause of acute myocardial infarction, especially in women and young patients. The majority of SCAD cases can be managed conservatively, but failure to revascularize in the setting of reduced coronary flow, ongoing ischemia, or hemodynamic instability can result in extensive infarction, heart failure, or death. Higher complication rates have historically been reported with percutaneous coronary intervention in SCAD because of iatrogenic dissection, non-luminal wiring, and hematoma propagation. The authors propose an algorithm for managing cases of high-risk SCAD in the cardiac catheterization laboratory where intervention is required to restore coronary flow and limit the infarction. The methods described include options to recanalize the vessel with cutting balloons and strategies for non-luminal wire position.