Coronary Dissection – Back to the Future – Finding Good in the Bad!

It has been recognized for decades that dissections occur as a mechanism of balloon angioplasty. A successful angioplasty result contains some degree of intimal splitting and disruption, which usually heals well. Nonetheless, some dissections are extensive, leading to serious ischaemic complications. The concept of therapeutic coronary dissection started evolving in the 1970s and seems to be a favourable mechanism for drug delivery in the current era of drug-coated balloons. This article will primarily focus on studies undertaken to understand the mechanism of balloon angioplasty and the morphological changes in the plaque post-balloon angioplasty. In the early days of balloon angioplasty, there was an enormous interest in dissections, mainly to prevent acute vessel closure events and to address the importance of their occurrence in relation to vessel restenosis. We will review the historical background, studies defining the clinical, angiographic and morphological patterns of the dissection spectrum and various currently evolving management strategies.