SS–11 A Challenging Pair: Management of an Ostial Lesion and Spontaneous Atherosclerotic Coronary Artery Dissection

Abstract

Introduction and Aim: Unlike spontaneous coronary artery dissection, coronary artery dissections developing on the background of atherosclerotic coronary artery disease are associated with plaque burden and structural abnormalities of the vessel wall. Ostial coronary lesions also represent a technically challenging subgroup in percutaneous coronary interventions (PCI) due to their anatomically critical location, involvement of the vascular orifice and proximal segment, requirement for precise stent deployment, and difficulty in achieving optimal lesion coverage. Herein, we present the management of a case presenting with both an ostial lesion and an atherosclerotic coronary artery dissection.

Case Report: A 56-year-old male patient presented to the emergency department complaining of typical chest pain. Initial electrocardiogram (ECG) revealed no ischemic changes, and cardiac troponin levels were negative. The patient underwent coronary angiography (CAG) with a preliminary diagnosis of unstable angina pectoris. CAG demonstrated non-critical plaques in the left anterior descending artery (LAD), an ostial 70–80% stenosis in the first diagonal branch (D1) (Medina 0-0-1 lesion), followed immediately by a coronary dissection line approximately 20 mm in length. Since the patient was hemodynamically stable, the lesion was an ostial diagonal stenosis, and distal TIMI 3 flow was preserved, conservative medical management was decided for both the coronary dissection and the ostial lesion. A follow-up CAG was scheduled to evaluate complete healing of the coronary dissection. During a two-week period of medical follow-up, the patient remained symptomatic, and a follow-up CAG was performed. Angiography showed no regression in the dissection line and persistent stenosis. Due to persistent symptoms and an unhealed dissection, inverted provisional PCI from the LAD to D1 was planned. Percutaneous transluminal coronary angioplasty was initially performed from the LAD to D1 using a 2.75x25 mm semi-compliant balloon, followed by the implantation of a 3.0x32 mm drug-eluting stent (DES). Finally, the proximal optimization technique was performed at the proximal segment of the stent using a 4.0x8 mm non-compliant balloon. Post-procedural full patency (TIMI 3 flow) was successfully achieved. The patient was discharged asymptomatically with optimized medical therapy.

Conclusion: In atherosclerotic coronary artery dissections, particularly in cases accompanied by ostial lesions, treatment strategy should be individualized by considering both the clinical status and anatomical features. Selected patients who are stable with preserved distal flow and no persistent ischemia or symptoms may be followed conservatively; however, revascularization should be considered in the presence of ongoing ischemia, refractory symptoms, or high-risk anatomy. While intravascular ultrasound (IVUS) or optical coherence tomography (OCT) provides significant contributions to determining the treatment strategy by evaluating the extent of dissection and plaque morphology, the intervention must be meticulously planned due to the technical challenges associated with ostial lesions.