Spontaneous coronary artery wall haematoma: success of conservative management despite alarming extension: a case report

Spontaneous coronary artery dissection (SCAD) is a particular mode of presentation of acute coronary syndrome. It preferentially affects the young woman with little or no classical risk factor for atheromatous disease.

In this report, we present a classical non-ST-segment myocardial infarction (NSTEMI) condition in link with a spontaneous coronary artery wall haematoma. A 43-year-old female patient who did not have any risk factors for atheromatous disease presented with NSTEMI. The coronary angiogram (CA) revealed a moderate smooth stenosis of the proximal left anterior descending artery (LAD) that ended just before the take-off of a septal branch. Intracoronary imaging by optical coherence tomography (OCT) visualized a large intramural haematoma reducing the coronary artery lumen. The patient was managed conservatively with antithrombotic regimen, nitrates, and close monitoring with repeated CA. Evolution was favourable despite striking extension of coronary haematoma towards distal LAD. She was then discharged and has been asymptomatic on follow-up visits. Planned repeat CA and OCT at 3 months showed a quite normal coronary artery appearance of the LAD with significant regression of haematoma.

Precise data regarding SCAD epidemiology remains to be determined. The angiographic pattern of our case recalls the Type 2 described by Saw team. But OCT was necessary to confirm the diagnosis. We manage our patient conservatively with close monitoring, as largely suggested by current state of the art, regarding the good haemodynamic status, and absence of ongoing ischaemia despite an evolution severe stenosis.