Management of Coronary Dissection During PCI

Immediate Management and Treatment

Consider use of intracoronary glycoprotein IIb/IIIa inhibitors in cases with large thrombus burden, no-reflow, or slow flow to improve procedural success, as recommended by the American College of Cardiology 1

For dissections with preserved flow and hemodynamic stability, consider conservative management if the dissection is limited and not flow-limiting, according to Praxis Medical Insights 2

Intravascular imaging should be used judiciously as it can potentially worsen the dissection or trigger abrupt vessel closure, as cautioned by the European Heart Journal 3
Only use intravascular imaging if the decision to proceed with revascularization has already been made, as recommended by the European Heart Journal 3

Dissections starting at the ostium with difficult true lumen identification carry higher risk for abrupt occlusion during PCI, as reported by the European Heart Journal 3
For dissections involving the left main coronary artery, consider emergency CABG if PCI is not feasible or fails, as recommended by the European Heart Journal 3
In cases of spontaneous coronary artery dissection (SCAD), PCI has approximately 50% failure rate, even with normal coronary flow at baseline, according to the European Heart Journal and Praxis Medical Insights 2, 3

For patients receiving drug-eluting stents (DES) during PCI for dissection in the setting of ACS, dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor should be given for at least 12 months, as recommended by the American Heart Association in Circulation 4
For non-ACS indications treated with DES, clopidogrel 75 mg daily should be given for at least 12 months if patients are not at high risk of bleeding, as recommended by the American Heart Association in Circulation 5
Consider aspirin 81 mg daily in preference to higher doses after PCI, as recommended by the American Heart Association in Circulation 5

Consider follow-up coronary angiography between 2 and 6 months after PCI for unprotected left main coronary dissections, as recommended by the American College of Cardiology 6
Monitor for signs of restenosis, which may require repeat intervention, as recommended by the American College of Cardiology 6