Recurrent SCAD Complicating Left Circumflex Stenting

Recurrent SCAD Complicating Left Circumflex Stenting | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Recurrent SCAD Complicating Left Circumflex Stenting Andrew Ndakotsu, Shaikh B. Iqbal, Ufuoma Mamoh, John C. Wang, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5727878/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome often requiring either conservative management or intervention. This case describes a 49-year-old woman with recurrent SCAD who developed a spiral dissection of the left circumflex artery during PCI, necessitating multiple stents. It highlights the challenges of SCAD, including dissection propagation. The report emphasizes procedural caution and tailored care to improve outcomes in high-risk SCAD patients. Spontaneous coronary artery dissection Percutaneous coronary intervention Acute Coronary Syndrome ACS SCAD. Figures Figure 1 Introduction Spontaneous coronary artery dissection (SCAD) is a rare and underdiagnosed cause of acute coronary syndrome (ACS) and sudden cardiac death, predominantly affecting women with few traditional cardiovascular risk factors [ 1 ]. Unlike atherosclerotic coronary artery disease, SCAD results from an intimal tear or intramural hematoma that compresses the coronary lumen, leading to myocardial ischemia. Percutaneous coronary intervention (PCI) plays a dual role, offering therapeutic revascularization while carrying the risk of dissection propagation. Here, we report a case of a 49-year-old woman with prior SCAD who developed a spiral dissection of the LCx following elective PCI. This case highlights the complexities of managing SCAD, particularly with PCI, and points novel insights into recurrence risk and therapeutic decision-making. Case Presentation A 49-year-old woman with a history of spontaneous coronary artery dissection (SCAD) four years prior presented with chest pain. Pharmacologic stress test revealed ischemic changes with ST depression in the inferior leads, though myocardial perfusion imaging showed no ischemia or scar. She had a history of hypertension, diabetes mellitus, tobacco use, and a family history notable for brain aneurysms in her father and recurrent strokes in her mother. Her previous SCAD episode involved a dissection originating in the distal left main (LM) artery, propagating into the proximal to mid-left anterior descending (LAD) artery, requiring drug-eluting stents (DES) in both the LM and LAD, with side-branch jailing of the Left circumflex (LCx). During the current admission, she underwent elective coronary angiography, which revealed a 95–99% stenosis at the ostium of the LCx. PCI was initiated with placement of a single DES. However, post-stenting, she experienced acute chest pain (10/10) with ST elevation on ECG. Repeat angiography revealed a spiral dissection propagating down the LCx, leading to near-occlusion seen in Fig. 1 . She required placement of three additional overlapping DES to restore vessel patency. Post-procedural troponin I levels were markedly elevated, peaking at 10,084 ng/dL (reference: 0–54 ng/dL). Following PCI, she was admitted to the ICU for hemodynamic monitoring and experienced a new-onset headache, raising concerns for cerebral vascular complications. Brain Magnetic Resonance Imaging MRI ruled out aneurysm or vascular malformations. She was discharged on dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor, along with a beta-blocker, statin, and ACE inhibitor. Follow-up evaluation with cardiology and rheumatology was scheduled to investigate possible fibromuscular dysplasia (FMD), a known predisposing condition for SCAD. Discussion SCAD is distinct from atherosclerotic coronary artery disease [1]. SCAD is driven by an intimal tear or intramural hematoma that compresses the true lumen. Predominantly affecting women (80-90% of cases), SCAD has several recognized risk factors, including fibromuscular dysplasia (FMD), systemic inflammatory diseases, and postpartum hormonal changes [2]. While the presence of traditional cardiovascular risk factors like hypertension, diabetes, and smoking are less common, they are known to propagate or increase the risk of recurrence in SCAD patients [2]. This patient’s predisposing factors included hypertension, diabetes, tobacco use, and a family history of vascular aneurysms and stroke, which prompted workup for fibromuscular dysplasia (FMD). The role of PCI in SCAD is controversial. Unlike atherosclerotic disease, SCAD often heals spontaneously with conservative management, making PCI unnecessary in many cases. However, in cases where there is persistent ischemia, hemodynamic instability, or high-risk coronary anatomy, PCI is indicated [3]. This case highlights the paradoxical nature of PCI in SCAD, as intervention to restore flow can propagate dissection. Here, the dissection occurred following stent placement, requiring three additional overlapping stents to resolve the occlusion. Multiple studies have shown that SCAD-PCI often requires multiple stents due to dissection propagation. In a systematic review of 13 observational studies including 1,801 SCAD patients, those undergoing PCI had significantly higher rates of dissection propagation and longer procedures [4]. SCAD can occur in any coronary vessel, but most commonly involves the LAD, reports indicate that up to 51% of patients have LAD involvement [5], while multivessel SCAD rates range from 10–15% [6]. Our patient's first episode involved the LAD with a spiral dissection emanating from the distal left main coronary artery dissection to the mid-LAD artery. As flow was restored in the distal LAD vessel, the left main dissection grew to involve the proximal left main. This demonstrates how inherently fragile SCAD coronary arteries are and how careful we need to be when managing these patients. In our patient, The LCx artery was particularly vulnerable to propagation of SCAD, especially with the lesion at the ostium. Lesions in bifurcation zones have unique flow characteristics, with plaque shift, carina shift, and shear stress, potentially leading to increased dissection risk [7]. The use of guidewires, balloons, and stents further increases the risk of propagation [4]. In this case, an initial ostial LCx lesion was treated with stenting, but a spiral dissection ensued, requiring three additional overlapping stents. The concept of carina shift is relevant here, as bifurcation stenting can displace the carina into the side branch, inducing flow disturbances and making that area more vulnerable to dissection in SCAD patients. SCAD management prioritizes conservative care. In a retrospective study, patients who underwent PCI had significantly higher risks of adverse in-hospital outcomes, including mortality, relative to those treated with optimized medical therapy [8]. A major reason for this is that patients who require PCI are generally more morbid in terms of presentation and co-morbidities than those who are treated conservatively [8]. PCI precautions including limited catheter manipulation, use of soft-tipped wires, minimal balloon inflation, and close angiographic monitoring for dissection propagation have been recommended and must be followed [4]. Unfortunately, patients with SCAD have a high risk of recurrence, with 50% of readmissions occurring within the first 3-5 days post-discharge [4]. Post-PCI complications include ventricular arrhythmias, myocardial infarction, decompensated heat failure and recurrent dissection [4,8]. It is important to be vigilant for these as they serve as a harbinger for mortality in SCAD patients [4,8] In this case, troponin levels peaked at 10,084 ng/dL, indicating a large myocardial infarction. Close post-PCI monitoring with serial ECGs and troponin assessments are crucial. This patient was discharged on DAPT along with beta-blockers, ACE inhibitors, and statins to prevent cardiovascular events. Recurrent SCAD poses significant challenges, especially during PCI, where dissection propagation risk is high. Conservative management is often safer, as guidewires, balloons, and stents can trigger dissections. However if PCI is indicated, close post-PCI monitoring is essential, and family history of aneurysms or strokes warrants screening for FMD. A cautious, risk-adjusted approach can improve outcomes for this high-risk cohort. By understanding the delicate nature of SCAD-PCI, clinicians can better anticipate complications, make risk-adjusted decisions, and improve outcomes for this high-risk cohort. Abbreviations LAD, left anterior descending; LCx, left circumflex; LM, left main; PCI, percutaneous coronary intervention Declarations Novel Teaching Points SCAD is a significant although often undetected factor contributing to acute coronary syndrome ACS, especially among younger women. Intra-Op Vigilance: PCI in SCAD is highly complex due to the risk of sudden dissection, requiring utmost intraoperative vigilance and prompt decision-making. Risk Factor Control: Controlling hypertension and other modifiable risk factors is crucial to reducing recurrence and preventing major adverse cardiac events (MACE). Data Availability No, I do not have any research data outside the submitted manuscript file. No datasets were generated or analysed during the current study. Funding No funding was received Ethics declarations The need for ethical approval was waived off by the ethics committee of MedStar Health due to the nature of the study. Consent for publication Informed consent was obtained from the patient in this study. References Saw J, Aymong E, Mancini GB, et al. Nonatherosclerotic coronary artery disease. J Am Coll Cardiol. 2017;70(9):1143–1158. Eleid MF, Guddeti RR, Tweet MS, et al. Coronary artery tortuosity in spontaneous coronary artery dissection. Circ Cardiovasc Interv. 2014;7(5):656–662. Alfonso F, Paulo M, Lennie V, et al. Spontaneous coronary artery dissection: new insights from the tip of the iceberg? Heart. 2012;98(14):1040–1049. Teruzzi G, Santagostino Baldi G, Gili S, Guarnieri G, Montorsi P, Trabattoni D. Spontaneous coronary artery dissections: A systematic review. J Clin Med. 2021;10(24):5925. doi: 10.3390/jcm10245925 . PMID: 34945221; PMCID: PMC8706333. Petrović M, Miljković T, Ilić A, Kovačević M, Čanković M, Dabović D, Stojšić Milosavljević A, Čemerlić Maksimović S, Jaraković M, Andrić D, Golubović M, Bjelobrk M, Bjelić S, Tadić S, Slankamenac J, Apostolović S, Djurović V, Milovančev A. Management and outcomes of spontaneous coronary artery dissection: a systematic review of the literature. Front Cardiovasc Med. 2024;11:1276521. doi: 10.3389/fcvm.2024.1276521 . PMID: 38298759; PMCID: PMC10829101. Saw J, Humphries K, Aymong E, Sedlak T, Prakash R, Starovoytov A, Mancini GBJ. Spontaneous Coronary Artery Dissection: Clinical Outcomes and Risk of Recurrence. J Am Coll Cardiol. 2017;70(9):1148–1158. doi: 10.1016/j.jacc.2017.06.053 . PMID: 28838364. EuroIntervention. The story of plaque shift and carina shift [Internet]. Available from: https://eurointervention.pcronline.com/article/the-story-of-plaque-shift-and-carina-shift . Accessed 2024 Dec 19. Krittanawong C, Castillo Rodriguez B, Ang SP, Qadeer YK, Wang Z, Alam M, Sharma S, Jneid H. Conservative Approach versus Percutaneous Coronary Intervention in Patients with Spontaneous Coronary Artery Dissection from a National Population-Based Cohort Study. Rev Cardiovasc Med. 2024;25(11):404. doi: 10.31083/j.rcm2511404 . PMID: 39618857; PMCID: PMC11607482. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5727878","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":400476519,"identity":"6d8ebfa1-ca37-4f4b-9ebc-4903b92aa6bb","order_by":0,"name":"Andrew Ndakotsu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA0klEQVRIiWNgGAWjYDACZhBxQEKGj4H5AJAlIUO0Fh42BrYEkBYeIq06wADUwmMAYhLWYs7Oe/DhjzMWPGz8Zz6/ulFjwcPAfvjoBnxaLJv5ko15bgAdJpG7zTrnGNBhPGlpN/BpMTjMYybN8AGkhXebcQ4bUIsEjxlBLZI/QFr4zzwzzvlHpBYJsMMYcpgf57YRp8XYmOcMyGFpZsy5fUAGQb+cP2P48MexOjl+/sOPP+d8AzLYDx/DqwUZsEmASWKVgwDzB1JUj4JRMApGwcgBANB4PLmHWbhwAAAAAElFTkSuQmCC","orcid":"","institution":"MedStar Union Memorial Hospital","correspondingAuthor":true,"prefix":"","firstName":"Andrew","middleName":"","lastName":"Ndakotsu","suffix":""},{"id":400476520,"identity":"ce098e90-dcce-43d7-88fe-c9ec1a4ad19b","order_by":1,"name":"Shaikh B. Iqbal","email":"","orcid":"","institution":"MedStar Union Memorial Hospital","correspondingAuthor":false,"prefix":"","firstName":"Shaikh","middleName":"B.","lastName":"Iqbal","suffix":""},{"id":400476521,"identity":"01a955b5-595e-47b1-bada-59384316c78a","order_by":2,"name":"Ufuoma Mamoh","email":"","orcid":"","institution":"MedStar Union Memorial Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ufuoma","middleName":"","lastName":"Mamoh","suffix":""},{"id":400476522,"identity":"07b2cbbe-1db7-486a-9e44-02293a14c660","order_by":3,"name":"John C. Wang","email":"","orcid":"","institution":"MedStar Union Memorial Hospital","correspondingAuthor":false,"prefix":"","firstName":"John","middleName":"C.","lastName":"Wang","suffix":""},{"id":400476523,"identity":"5ef8548b-91de-4574-b68b-6273fafcaf5b","order_by":4,"name":"Sriram Padmanabhan","email":"","orcid":"","institution":"MedStar Union Memorial Hospital","correspondingAuthor":false,"prefix":"","firstName":"Sriram","middleName":"","lastName":"Padmanabhan","suffix":""},{"id":400476524,"identity":"8d9f7378-a951-4ae4-b09b-bac21fd78523","order_by":5,"name":"Anthony G. Kaliyadan","email":"","orcid":"","institution":"MedStar Union Memorial Hospital","correspondingAuthor":false,"prefix":"","firstName":"Anthony","middleName":"G.","lastName":"Kaliyadan","suffix":""}],"badges":[],"createdAt":"2024-12-28 23:08:06","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5727878/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5727878/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":73789297,"identity":"6ff5c727-97a2-45c2-b1f3-4540d49234d3","added_by":"auto","created_at":"2025-01-14 16:40:20","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":242044,"visible":true,"origin":"","legend":"\u003cp\u003e(A) Left coronary angiogram demonstrating the left main (LM) and left circumflex (LCx) coronary artery dissection prior to intervention (yellow arrows). (B) Wiring of the left anterior descending (LAD) coronary artery and LCx during percutaneous coronary intervention (PCI). (C) Post-PCI angiogram demonstrating resolution of the spiral dissection in the LCx after balloon dilation (white arrow).\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5727878/v1/5d7c89fbf1b364ce9b6dd33a.png"},{"id":102745674,"identity":"8257689c-bfd3-4202-b4cb-a080309efd17","added_by":"auto","created_at":"2026-02-16 08:53:15","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":616482,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5727878/v1/17605380-1859-43ac-a827-e8974f1c486e.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Recurrent SCAD Complicating Left Circumflex Stenting","fulltext":[{"header":"Introduction","content":"\u003cp\u003eSpontaneous coronary artery dissection (SCAD) is a rare and underdiagnosed cause of acute coronary syndrome (ACS) and sudden cardiac death, predominantly affecting women with few traditional cardiovascular risk factors [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Unlike atherosclerotic coronary artery disease, SCAD results from an intimal tear or intramural hematoma that compresses the coronary lumen, leading to myocardial ischemia. Percutaneous coronary intervention (PCI) plays a dual role, offering therapeutic revascularization while carrying the risk of dissection propagation. Here, we report a case of a 49-year-old woman with prior SCAD who developed a spiral dissection of the LCx following elective PCI. This case highlights the complexities of managing SCAD, particularly with PCI, and points novel insights into recurrence risk and therapeutic decision-making.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eA 49-year-old woman with a history of spontaneous coronary artery dissection (SCAD) four years prior presented with chest pain. Pharmacologic stress test revealed ischemic changes with ST depression in the inferior leads, though myocardial perfusion imaging showed no ischemia or scar. She had a history of hypertension, diabetes mellitus, tobacco use, and a family history notable for brain aneurysms in her father and recurrent strokes in her mother. Her previous SCAD episode involved a dissection originating in the distal left main (LM) artery, propagating into the proximal to mid-left anterior descending (LAD) artery, requiring drug-eluting stents (DES) in both the LM and LAD, with side-branch jailing of the Left circumflex (LCx).\u003c/p\u003e \u003cp\u003eDuring the current admission, she underwent elective coronary angiography, which revealed a 95\u0026ndash;99% stenosis at the ostium of the LCx. PCI was initiated with placement of a single DES. However, post-stenting, she experienced acute chest pain (10/10) with ST elevation on ECG. Repeat angiography revealed a spiral dissection propagating down the LCx, leading to near-occlusion seen in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. She required placement of three additional overlapping DES to restore vessel patency. Post-procedural troponin I levels were markedly elevated, peaking at 10,084 ng/dL (reference: 0\u0026ndash;54 ng/dL). Following PCI, she was admitted to the ICU for hemodynamic monitoring and experienced a new-onset headache, raising concerns for cerebral vascular complications. Brain Magnetic Resonance Imaging MRI ruled out aneurysm or vascular malformations. She was discharged on dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor, along with a beta-blocker, statin, and ACE inhibitor. Follow-up evaluation with cardiology and rheumatology was scheduled to investigate possible fibromuscular dysplasia (FMD), a known predisposing condition for SCAD.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eSCAD is distinct from atherosclerotic coronary artery disease [1]. SCAD is driven by an intimal tear or intramural hematoma that compresses the true lumen. Predominantly affecting women (80-90% of cases), SCAD has several recognized risk factors, including fibromuscular dysplasia (FMD), systemic inflammatory diseases, and postpartum hormonal changes [2]. While the presence of traditional cardiovascular risk factors like hypertension, diabetes, and smoking are less common, they are known to propagate or increase the risk of recurrence in SCAD patients [2]. This patient’s predisposing factors included hypertension, diabetes, tobacco use, and a family history of vascular aneurysms and stroke, which prompted workup for fibromuscular dysplasia (FMD).\u003c/p\u003e\n\u003cp\u003eThe role of PCI in SCAD is controversial. Unlike atherosclerotic disease, SCAD often heals spontaneously with conservative management, making PCI unnecessary in many cases. However, in cases where there is persistent ischemia, hemodynamic instability, or high-risk coronary anatomy, PCI is indicated [3]. This case highlights the paradoxical nature of PCI in SCAD, as intervention to restore flow can propagate dissection. Here, the dissection occurred following stent placement, requiring three additional overlapping stents to resolve the occlusion. Multiple studies have shown that SCAD-PCI often requires multiple stents due to dissection propagation. In a systematic review of 13 observational studies including 1,801 SCAD patients, those undergoing PCI had significantly higher rates of dissection propagation and longer procedures [4].\u003c/p\u003e\n\u003cp\u003eSCAD can occur in any coronary vessel, but most commonly involves the LAD, reports indicate that up to 51% of patients have LAD involvement [5], while multivessel SCAD rates range from 10–15% [6]. Our patient's first episode involved the LAD with a spiral dissection emanating from the distal left main coronary artery dissection to the mid-LAD artery. As flow was restored in the distal LAD vessel, the left main dissection grew to involve the proximal left main. This demonstrates how inherently fragile SCAD coronary arteries are and how careful we need to be when managing these patients.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn our patient, The LCx artery was particularly vulnerable to propagation of SCAD, especially with the lesion at the ostium. Lesions in bifurcation zones have unique flow characteristics, with plaque shift, carina shift, and shear stress, potentially leading to increased dissection risk [7]. The use of guidewires, balloons, and stents further increases the risk of propagation [4]. In this case, an initial ostial LCx lesion was treated with stenting, but a spiral dissection ensued, requiring three additional overlapping stents. The concept of carina shift is relevant here, as bifurcation stenting can displace the carina into the side branch, inducing flow disturbances and making that area more vulnerable to dissection in SCAD patients.\u003c/p\u003e\n\u003cp\u003eSCAD management prioritizes conservative care. In a retrospective study, patients who \u0026nbsp;underwent PCI had significantly higher risks of adverse in-hospital outcomes, including mortality, relative to those treated with optimized medical therapy [8]. A major reason for this is that patients who require PCI are generally more morbid in terms of presentation and co-morbidities than those who are treated conservatively [8]. \u0026nbsp;PCI precautions including limited catheter manipulation, use of soft-tipped wires, minimal balloon inflation, and close angiographic monitoring for dissection propagation have been recommended and must be followed [4].\u003c/p\u003e\n\u003cp\u003eUnfortunately, patients with SCAD have a high risk of recurrence, with 50% of readmissions occurring within the first 3-5 days post-discharge [4]. Post-PCI complications include ventricular arrhythmias, myocardial infarction, decompensated heat failure and recurrent dissection [4,8]. It is important to be vigilant for these as they serve as a harbinger for mortality in SCAD patients [4,8] In this case, troponin levels peaked at 10,084 ng/dL, indicating a large myocardial infarction. Close post-PCI monitoring with serial ECGs and troponin assessments are crucial. This patient was discharged on DAPT along with beta-blockers, ACE inhibitors, and statins to prevent cardiovascular events.\u003c/p\u003e\n\u003cp\u003eRecurrent SCAD poses significant challenges, especially during PCI, where dissection propagation risk is high. Conservative management is often safer, as guidewires, balloons, and stents can trigger dissections. However if PCI is indicated, close post-PCI monitoring is essential, and family history of aneurysms or strokes warrants screening for FMD. A cautious, risk-adjusted approach can improve outcomes for this high-risk cohort.\u003c/p\u003e\n\u003cp\u003eBy understanding the delicate nature of SCAD-PCI, clinicians can better anticipate complications, make risk-adjusted decisions, and improve outcomes for this high-risk cohort.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eLAD, left anterior descending; LCx, left circumflex; LM, left main; PCI, percutaneous coronary intervention\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eNovel Teaching Points\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eSCAD is a significant although often undetected factor contributing to acute coronary syndrome ACS, especially among younger women.\u003c/li\u003e\n \u003cli\u003eIntra-Op Vigilance: PCI in SCAD is highly complex due to the risk of sudden dissection, requiring utmost intraoperative vigilance and prompt decision-making.\u003c/li\u003e\n \u003cli\u003eRisk Factor Control: Controlling hypertension and other modifiable risk factors is crucial to reducing recurrence and preventing major adverse cardiac events (MACE).\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo, I do not have any research data outside the submitted manuscript file.\u0026nbsp;No datasets were generated or analysed during the current study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding was received\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics declarations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe need for ethical approval was waived off by the ethics committee of MedStar Health due to the nature of the study. \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from the patient in this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSaw J, Aymong E, Mancini GB, et al. Nonatherosclerotic coronary artery disease. J Am Coll Cardiol. 2017;70(9):1143\u0026ndash;1158.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEleid MF, Guddeti RR, Tweet MS, et al. Coronary artery tortuosity in spontaneous coronary artery dissection. Circ Cardiovasc Interv. 2014;7(5):656\u0026ndash;662.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlfonso F, Paulo M, Lennie V, et al. Spontaneous coronary artery dissection: new insights from the tip of the iceberg? Heart. 2012;98(14):1040\u0026ndash;1049.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTeruzzi G, Santagostino Baldi G, Gili S, Guarnieri G, Montorsi P, Trabattoni D. Spontaneous coronary artery dissections: A systematic review. J Clin Med. 2021;10(24):5925. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3390/jcm10245925\u003c/span\u003e\u003cspan address=\"10.3390/jcm10245925\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 34945221; PMCID: PMC8706333.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePetrović M, Miljković T, Ilić A, Kovačević M, Čanković M, Dabović D, Stojšić Milosavljević A, Čemerlić Maksimović S, Jaraković M, Andrić D, Golubović M, Bjelobrk M, Bjelić S, Tadić S, Slankamenac J, Apostolović S, Djurović V, Milovančev A. Management and outcomes of spontaneous coronary artery dissection: a systematic review of the literature. Front Cardiovasc Med. 2024;11:1276521. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3389/fcvm.2024.1276521\u003c/span\u003e\u003cspan address=\"10.3389/fcvm.2024.1276521\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 38298759; PMCID: PMC10829101.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSaw J, Humphries K, Aymong E, Sedlak T, Prakash R, Starovoytov A, Mancini GBJ. Spontaneous Coronary Artery Dissection: Clinical Outcomes and Risk of Recurrence. J Am Coll Cardiol. 2017;70(9):1148\u0026ndash;1158. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jacc.2017.06.053\u003c/span\u003e\u003cspan address=\"10.1016/j.jacc.2017.06.053\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 28838364.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEuroIntervention. The story of plaque shift and carina shift [Internet]. 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PMID: 39618857; PMCID: PMC11607482.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Spontaneous coronary artery dissection, Percutaneous coronary intervention Acute Coronary Syndrome, ACS, SCAD.","lastPublishedDoi":"10.21203/rs.3.rs-5727878/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5727878/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eSpontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome often requiring either conservative management or intervention. This case describes a 49-year-old woman with recurrent SCAD who developed a spiral dissection of the left circumflex artery during PCI, necessitating multiple stents. It highlights the challenges of SCAD, including dissection propagation. The report emphasizes procedural caution and tailored care to improve outcomes in high-risk SCAD patients.\u003c/p\u003e","manuscriptTitle":"Recurrent SCAD Complicating Left Circumflex Stenting","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-01-14 16:32:09","doi":"10.21203/rs.3.rs-5727878/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9a01d460-662d-4b78-b9de-49488170095f","owner":[],"postedDate":"January 14th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-02-11T13:27:20+00:00","versionOfRecord":[],"versionCreatedAt":"2025-01-14 16:32:09","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5727878","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5727878","identity":"rs-5727878","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}