Spontaneous Coronary Artery Dissection or Coronary Atherosclerosis

BACKGROUND: Spontaneous coronary artery dissection (SCAD) and atherosclerosis may appear similar on coronary imaging. CASE SUMMARY: A 62-year-old woman with fibromuscular dysplasia, dyslipidemia, and diabetes presented with chest discomfort. Coronary computed tomography angiography suggested left anterior descending artery (LAD) SCAD, and invasive coronary angiography (ICA) showed possible type 3 SCAD. Intracoronary imaging (ICI) was not performed, and she was treated medically. DISCUSSION: Recurrent chest pain prompted repeat imaging. Follow-up computed tomography angiography suggested persistent LAD SCAD. Repeat ICA revealed high-grade proximal LAD and first diagonal stenoses, confirmed as atherosclerosis on ICI. Percutaneous coronary intervention with 2 drug-eluting stents relieved symptoms. At 5 months, recurrent symptoms from severe LAD stenosis proximal to the stents were treated with drug-eluting stents, and ICA at 8 months showed in-stent restenosis, managed by balloon angioplasty. TAKE-HOME MESSAGES: ICI is essential when type 3 SCAD is suspected and angiography is indeterminate. Stent-edge disease and in-stent restenosis highlight important causes of recurrent symptoms after percutaneous coronary intervention.