Bioresorbable scaffolds and drug-eluting balloons for the management of spontaneous coronary artery dissections

Bioresorbable scaffolds and drug-eluting balloons for the management of spontaneous coronary artery dissections

Vasileios F. Panoulas1,2, Alfonso Ielasi3

1Harefield and Royal Brompton Hospital NHS Trust, London, UK; 2National Heart and Lung Institute, Imperial College London, London, UK; 3Cardiology Division, Bolognini Hospital Seriate, ASST Bergamo Est, Italy

Correspondence to: Alfonso Ielasi, MD, FESC. Cardiology Division, Bolognini Hospital Seriate, Via Paderno 21, 24068, Seriate (BG), Italy. Email:

Submitted Sep 19, 2016. Accepted for publication Sep 26, 2016.

doi: 10.21037/jtd.2016.10.54

Spontaneous coronary artery dissection (SCAD) is well recognised cause of acute coronary syndromes (ACS), typically affecting female and younger individuals with no underlying atherosclerotic disease (1). SCAD is a relatively rare presentation of ACS however its reported prevalence varies from as low as 0.2% in angiographic studies (2) to as high as 4% of ACS cases in studies using optimal coherence tomography (OCT) (3).

Diagnosis of SCAD was traditionally made with coronary angiography. However, new imaging modalities especially OCT and intravascular ultrasound, have improved diagnostic accuracy and provided new insights on management (1). The optimal treatment strategy remains controversial and undetermined, as no randomised trials comparing conservative versus revascularization strategies have been carried out (4). The management of SCAD in the majority of cases could be conservative (5), as per expert opinions, however in some specific situations revascularization should be considered (6). In particular, SCADs located at a proximal coronary segment or causing a lumen diameter limitation >70% and/or sub-optimal distal TIMI flow (<3), hemodynamic instability, ventricular arrhythmias, should be treated where feasible with percutaneous coronary intervention (PCI) or even coronary artery bypass grafting (CABG) (1). It should be however noted that the reported success rates of PCI in this patient subset vary from 47% (5) to 64% (6) and 72.5% (7) in different national registries, highlighting the multiple challenges operators face when treating these lesions.

Bioresorbable vascular scaffolds (BVS) have emerged as an alternative to metallic stents, promising to provide mechanical support and drug-delivery functions similar to those of drug-eluting stents (DES) for approximately 1 year, followed by complete bioresorption and full restoration of vessel vasomotion over 3-4 years. Recent studies (8-10) have revealed similar one-year outcomes in patients treated with BRS compared to those treated with new generation everolimus-eluting stents, albeit with some concerns on higher device thrombosis rates amongst BRS (11-13) particularly when implanted in small vessels (8). BRSs appear to be an attractive treatment strategy for patients with SCAD, given that these patients are often young and need long segments of struts coverage to contain the dissection. The “full plastic jacket” concept has been introduced in patients with long diffuse disease with acceptable mid-term outcomes (14). Recent case reports demonstrated the feasibility of “full plastic jacket” using overlapping BRS in patients with long SCAD (15-17). In the largest case series (N=18) of SCAD ACS patients treated with BRS (18), overlapping BRS were implanted in 11 (61.1%) patients whereas the vessel more often treated was the LAD (55.5% of cases). A third of patients presented with STEMI whereas 5/18 (28%) had a NSTEMI. Mean patient age was only 49 whereas 10 (65.6%) were females. At the median 18-month clinical follow-up no adverse events were reported. Intracoronary imaging was performed in 50% of patients. Concerns regarding overlapping scaffolds and higher risk of restenosis have recently been alleviated, albeit not eclipsed, by the presentation of propensity matched studies showing similar 1-year outcomes in patients treated with overlapping scaffolds and those with overlapping metallic stents (19,20). Operators should also be aware of the increased risk of BRS thrombosis in the early stages after implantation (12), which however can be often attributed to poor implantation technique (omission of aggressive lesion preparation and post-dilatation) particularly in the STEMI setting (21,22).

In a recently published registry, Cortese et al. (23) for the first time suggested avoiding stents in dissected vessels with good flow, following the use of drug eluting balloon (DEB) for CAD. This intriguing study provides food for thought, as a DEB strategy, allowing for TIMI 3 flow down the dissected vessel in SCAD patients may indeed prove sufficient to allow spontaneous healing. The argument against such a strategy, however, would be that the weaker wall integrity and presence of intramural haematoma in patients with SCAD would lead to higher rates of acute recoil compared to patients with atherosclerotic CAD (24). We would rather favor BRS over DEB in patients with SCAD and coronary flow compromise, as the temporary scaffold would avoid acute vessel occlusion caused by expansion of the mural haematoma and acute recoil.

The reality is that there is no compelling randomised evidence to support the various treatment options (BRS or DEB or indeed permanent, metallic DES) available for SCAD patients with high-risk features (i.e., ongoing ischaemia with distal TIMI flow less than 3, fatal arrhythmias, cardiogenic shock). BRS and DEB are indeed very attractive strategies as SCAD is often seen in young individuals and often involves long segments of the coronary tree. Future randomized controlled trials comparing BRS versus DEB versus new generation metallic DES would be the only way forward, to identify the optimal interventional management for this relatively rare, yet daunting condition for every interventional cardiologist.




Provenance: This is an invited Commentary commissioned by the Section Editor Xiaoyan Wang (Phd student in Cardiology, Fudan University Shanghai Medical College, Shanghai, China).

Conflicts of Interest: The authors have no conflicts of interest to declare.

Comment on: Wu S, Liu W, Zhao Y, et al. Revascularization treatment for spontaneous coronary artery dissection: A reconsideration of drug-coated balloons and bioresorbable vascular scaffold. Int J Cardiol 2016;209:49-50.


  1. Saw J, Mancini GB, Humphries KH. Contemporary Review on Spontaneous Coronary Artery Dissection. J Am Coll Cardiol 2016;68:297-312. [Crossref] [PubMed]
  2. Mortensen KH, Thuesen L, Kristensen IB, et al. Spontaneous coronary artery dissection: a Western Denmark Heart Registry study. Catheter Cardiovasc Interv 2009;74:710-7. [Crossref] [PubMed]
  3. Nishiguchi T, Tanaka A, Ozaki Y, et al. Prevalence of spontaneous coronary artery dissection in patients with acute coronary syndrome. Eur Heart J Acute Cardiovasc Care 2016;5:263-70. [Crossref] [PubMed]
  4. Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014;130:e344-426. [Crossref] [PubMed]
  5. Tweet MS, Eleid MF, Best PJ, et al. Spontaneous coronary artery dissection: revascularization versus conservative therapy. Circ Cardiovasc Interv 2014;7:777-86. [Crossref] [PubMed]
  6. Saw J, Aymong E, Sedlak T, et al. Spontaneous coronary artery dissection: association with predisposing arteriopathies and precipitating stressors and cardiovascular outcomes. Circ Cardiovasc Interv 2014;7:645-55. [Crossref] [PubMed]
  7. Lettieri C, Zavalloni D, Rossini R, et al. Management and Long-Term Prognosis of Spontaneous Coronary Artery Dissection. Am J Cardiol 2015;116:66-73. [Crossref] [PubMed]
  8. Ellis SG, Kereiakes DJ, Metzger DC, et al. Everolimus-Eluting Bioresorbable Scaffolds for Coronary Artery Disease. N Engl J Med 2015;373:1905-15. [Crossref] [PubMed]
  9. Gao R, Yang Y, Han Y, et al. Bioresorbable Vascular Scaffolds Versus Metallic Stents in Patients With Coronary Artery Disease: ABSORB China Trial. J Am Coll Cardiol 2015;66:2298-309. [Crossref] [PubMed]
  10. Kimura T, Kozuma K, Tanabe K, et al. A randomized trial evaluating everolimus-eluting Absorb bioresorbable scaffolds vs. everolimus-eluting metallic stents in patients with coronary artery disease: ABSORB Japan. Eur Heart J 2015;36:3332-42. [Crossref] [PubMed]
  11. Cassese S, Byrne RA, Ndrepepa G, et al. Everolimus-eluting bioresorbable vascular scaffolds versus everolimus-eluting metallic stents: a meta-analysis of randomised controlled trials. Lancet 2016;387:537-44. [Crossref] [PubMed]
  12. Lipinski MJ, Escarcega RO, Baker NC, et al. Scaffold Thrombosis After Percutaneous Coronary Intervention With ABSORB Bioresorbable Vascular Scaffold: A Systematic Review and Meta-Analysis. JACC Cardiovasc Interv 2016;9:12-24. [Crossref] [PubMed]
  13. Capodanno D, Gori T, Nef H, et al. Percutaneous coronary intervention with everolimus-eluting bioresorbable vascular scaffolds in routine clinical practice: early and midterm outcomes from the European multicentre GHOST-EU registry. EuroIntervention 2015;10:1144-53. [Crossref] [PubMed]
  14. Kawamoto H, Panoulas VF, Sato K, et al. Short-term outcomes following "full-plastic jacket" everolimus-eluting bioresorbable scaffold implantation. Int J Cardiol 2014;177:607-9. [Crossref] [PubMed]
  15. Sengottuvelu G, Rajendran R. Full polymer jacketing for long-segment spontaneous coronary artery dissection using bioresorbable vascular scaffolds. JACC Cardiovasc Interv 2014;7:820-1. [Crossref] [PubMed]
  16. Macaya F, Peral V, Alameda M, et al. Bioresorbable Scaffolds to Treat Spontaneous Coronary Artery Dissection. Circ Cardiovasc Interv 2016;9:e003133. [Crossref] [PubMed]
  17. Cockburn J, Yan W, Bhindi R, et al. Spontaneous coronary artery dissection treated with bioresorbable vascular scaffolds guided by optical coherence tomography. Can J Cardiol 2014;30:1461.e1-3. [Crossref] [PubMed]
  18. Ielasi A, Cortese B, Tarantini G, et al. Sealing spontaneous coronary artery dissection with bioresorbable vascular scaffold implantation: Data from the prospective "Registro Absorb Italiano" (RAI Registry). Int J Cardiol 2016;212:44-6. [Crossref] [PubMed]
  19. Panoulas VF, Kawamoto H, Sato K, et al. Clinical Outcomes After Implantation of Overlapping Bioresorbable Scaffolds vs New Generation Everolimus Eluting Stents. Rev Esp Cardiol (Engl Ed) 2016. [Epub ahead of print].
  20. Biscaglia S, Ugo F, Ielasi A, et al. Bioresorbable Scaffold vs. Second Generation Drug Eluting Stent in Long Coronary Lesions requiring Overlap: A Propensity-Matched Comparison (the UNDERDOGS study). Int J Cardiol 2016;208:40-5. [Crossref] [PubMed]
  21. Colombo A, Ruparelia N. Who Is Thrombogenic: The Scaffold or the Doctor? Back to the Future! JACC Cardiovasc Interv 2016;9:25-7. [Crossref] [PubMed]
  22. Ielasi A, Varricchio A, Campo G, et al. A prospective evaluation of a standardized strategy for the use of a polymeric everolimus-eluting bioresorbable scaffold in ST-segment elevation myocardial infarction: rationale and design of the BVS STEMI STRATEGY-IT Study. Catheter Cardiovasc Interv 2016. [Epub ahead of print]. [Crossref] [PubMed]
  23. Cortese B, Silva Orrego P, Agostoni P, et al. Effect of Drug-Coated Balloons in Native Coronary Artery Disease Left With a Dissection. JACC Cardiovasc Interv 2015;8:2003-9. [Crossref] [PubMed]
  24. Wu S, Liu W, Zhao Y, et al. Revascularization treatment for spontaneous coronary artery dissection: A reconsideration of drug-coated balloons and bioresorbable vascular scaffold. Int J Cardiol 2016;209:49-50. [Crossref] [PubMed]
Cite this article as: Panoulas VF, Ielasi A. Bioresorbable scaffolds and drug-eluting balloons for the management of spontaneous coronary artery dissections. J Thorac Dis 2016;8(10):E1328-E1330. doi: 10.21037/jtd.2016.10.54