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前言 冠状动脉夹层(coronary artery dissection，CAD)非常少见，外伤引起的冠状动脉夹层更少见。冠状动脉夹层压迫冠状动脉，很容易引起心肌梗死。外伤患者如果不警惕冠状动脉夹层，很容易漏诊，措施抢救机会。 冠状动脉夹层的发展过程一般是冠状动脉夹层，出血，血肿压迫冠状动脉，冠状动脉缺血，导致心肌梗死，大多数有胸痛症状。 诊断类似冠心病、心肌梗死，冠状动脉增强CT简单方便，磁共振也有价值，另外冠状动脉造影也是常用的方法之一。冠状动脉内成像技术如光学相干断层扫描(optical coherence tomography，OCT)和血管内超声对确诊非常有用，但是并发症高，很多医院，是绝大多数医院都没有条件开展这个技术。 治疗类似一般的心肌梗死（最大区别是冠状动脉夹层一般禁忌抗凝），严重的要安支架，恢复冠状动脉血流，轻微的可以抗血小板保守治疗。 1.柔术训练失误造成的创伤性冠状动脉夹层 参考文献：投掷死亡:柔术训练造成的创伤性冠状动脉夹层。Haywood ST, Patel K, Gallo D, Silver K, Jouriles N. Throws of Death: Traumatic Coronary Artery Dissection Resulting From Jiu Jitsu Training. J Emerg Med. 2020;58(1):63-66. doi:10.1016/j.jemermed.2019.09.037 杂志：J Emerg Med（JCR分区，Q3） 作者单位：Northeast Ohio Medical College, Rootstown, Ohio; Department of Emergency Medicine, Summa Health, Akron, Ohio. 简介：A 45-year-old previously healthy man presented to the ED after a blunt chest injury. He was practicing jiu-jitsu and had been instructing a novice martial artist when the novice unintentionally rolled onto the patient’s chest, driving his elbow into the patient’s sternum. The patient had sudden severe midsternal chest pain that prompted him to call emergency medical services for transport to the ED. 一名45岁的健康男性因胸部钝性损伤就诊于急诊科。他正在练习柔术，正在指导一位新手武术，这时这位新手无意中打到了病人的胸部，肘部撞到了病人胸骨。患者突然出现严重的胸骨中部胸痛，这促使他拨打紧急医疗服务电话，将其送往急诊室。 Chest radiography showed no evidence of traumatic injury.胸片没有外伤证据。
The patient was emergently transferred to the catheterization laboratory. Upon arrival to the catheterization laboratory, the patient deteriorated into ventricular fibrillation. He was successfully defibrillated, went back into ventricular fibrillation, and was successfully defibrillated again. 病人突然反复室颤。 Cardiac catherization revealed a proximal left anterior descending (LAD) artery occlusion with coronary dissection (Figure 2). This dissection was confirmed by intravascular ultrasonography. A drug-eluting stent was placed over the lesion that restored thrombolysis in myocardial infarction grade blood flow (Figure 3). 心导管检查显示左前降支(LAD)近端闭塞伴冠状动脉夹层(图2)。血管内超声检查证实该夹层。在病变部位放置药物洗脱支架，恢复心肌梗死级血流溶栓(图3)。
Blunt thoracic trauma can be divided into 2 categories based on mechanism: high energy and low energy. Highenergy mechanisms, such as motor vehicle accidents, are more likely to result in life-threatening injuries with patients more likely to present critically ill. Rib fracture is the most common thoracic injury, present in 10% of all blunt chest traumas and almost 40% of patients who sustain severe nonpenetrating trauma (3). 钝性胸外伤根据作用机制可分为高能和低能两类。高能机制，如机动车事故，更有可能导致危及生命的伤害，患者更有可能出现危重症。肋骨骨折是最常见的胸部损伤，10%的钝性胸部创伤和近40%的严重非穿透性创伤患者都存在肋骨骨折（3）。 Low-energy mechanisms, such as sports injuries and falls, commonly result in rib fractures. These injuries are usually mild compared with those sustained under high-energy mechanisms. Pulmonary therapy, pain control, and secretion management are the mainstays of treatment for these injuries (4). 低能量机制，如运动损伤和跌倒，通常会导致肋骨骨折。与高能机制下的损伤相比，这些损伤通常是轻微的。肺部治疗、疼痛控制和分泌物管理是治疗这些损伤的主要方法(4)。 CAD that results from a low-energy mechanism blunt thoracic trauma is rare. The overall incidence of cardiacrelated complications in patients who present to the ED with blunt chest trauma is low (approximately 0.1%) (5). 低能量机制钝性胸外伤导致CAD（冠状动脉夹层）是罕见的。钝性胸外伤患者在急诊科出现心脏相关并发症的总体发生率较低(约为0.1%)(5)。 suffered a low-energy thoracic trauma and had no rib or sternal fractures. Our patient was noted to have no tenderness to palpation of the anterior chest wall. 我们的患者遭受了低能量的胸部创伤，没有肋骨或胸骨骨折。我们的病人，胸部前壁触诊没有压痛。 2.锻炼时摔倒导致冠状动脉夹层 参考文献：Dreger H, Haug M, Möckel M. Dressler Syndrome in Anterior Myocardial Infarction Due To Traumatic Coronary Artery Dissection. Dtsch Arztebl Int. 2019;116(33-34):562. doi:10.3238/arztebl.2019.0562 杂志：Deutsches Arzteblatt International（JCR分区，Q1） 作者单位：Medizinische Klinik mit Schwerpunkt Kardiologie und Angiologie, Campus Charité Mitte, Charité—Universitätsmedizin Berlin 简介：A 36-year-old male physician presented to our emergency department with back pain after a fall while exercising on a trampoline. A fracture was excluded by X-ray and the patient was discharged. Two weeks later the patient presented again, this time with progressive fatigue, a temperature of up to 39.3°C, and thoracic pain on respiration. Clinical chemistry found elevated parameters of inflammation (leukocytes 16.9/nL, C-reactive protein [CRP] 159 mg/L). Echocardiography revealed a 3-cm pericardial effusion and an apical hypokinesia with left ventricular thrombus; computed tomography showed corresponding morphological findings. After pericardiocentesis, cardiac catheterization demonstrated traumatic dissection of the left anterior descending coronary artery with older thrombi, which was then treated by implantation of a stent. Inflammatory markers normalized under antiphlogistic therapy. The patient was discharged after 2 weeks with mild exercise dyspnea. 一位36岁的男医生在蹦床上锻炼时摔倒，背部疼痛，来到我们的急诊科。X光检查排除骨折，患者出院。两周后，患者再次出现症状，这次是进行性疲劳，体温高达39.3°C，呼吸时胸痛。临床化学发现炎症参数升高（白细胞16.9/nL，C反应蛋白[CRP]159 mg/L）。超声心动图显示3厘米心包积液和心尖运动障碍伴左心室血栓；计算机断层扫描显示相应的形态学表现。心包穿刺术后，心导管插入术显示左前降支冠状动脉创伤性夹层伴陈旧性血栓，随后植入支架进行治疗。抗炎治疗下炎症标志物正常化。患者在2周后出院，只有轻度运动性呼吸困难。
3.被丈夫踢到后背导致冠状动脉夹层 参考文献：年轻女性被踢到后背导致冠状动脉夹层。Ipek E, Ermis E, Demirelli S, Yıldırım E, Yolcu M, Sahin BD. Traumatic Coronary Artery Dissection in a Young Woman after a Kick to Her Back. Korean J Thorac Cardiovasc Surg. 2015;48(4):281-284. doi:10.5090/kjtcs.2015.48.4.281 杂志：Korean J Thorac Cardiovasc Surg（JCR分区） 作者单位：Department of Cardiology, Erzurum Region Training and Research Hospital. 简介：A 38-year-old woman was admitted to our outpatient clinic with accelerating back pain and fatigue following a kick to her back by her husband two days previously. On her physical examination, an ecchymotic area on her back between the scapulae was observed. She had pallor, her blood pressure was 80/60 mmHg in both arms, and was tachycardic on auscultation. ST segment elevations were observed in the D1, aVL, and V2 leads, along with accelerated idioventricular rhythm (Fig. 1). Transthoracic echocardiography demonstrated akinesia of the anterior septal, apical, basal-mid septal, and basal-mid anterior walls, and her ejection fraction was 20%. She was immediately transferred to the catheterization unit. We performed coronary angiography after introducing a 6-Fr sheath through the right femoral artery. We detected a dissection of the left main artery, the left anterior descending artery (LAD), and the circumflex artery, originating from the middle portion of the left main coronary artery (LMCA) (Figs. 2 and 3, Supplemental Videos 1, 2). After emergency cardiovascular surgery consultation, she was transferred to the operation room. A saphenous vein was grafted to the distal LAD. During the intraoperative evaluation of the epicardial vessels, our team of cardiac surgeons did not plan to place a bypass graft to the circumflex artery because it was thin and non-dominant. Since the patient was hypotensive under noradrenaline and dopamine infusions, she was transferred to the cardiovascular surgery intensive care unit on an extracorporeal membrane oxygenator (ECMO) and intra-aortic balloon pump (IABP). During follow-up, her blood pressure remained low, at approximately 60/40 mmHg, despite aggressive inotropic and mechanical support. On the second postoperative day, although the patient’s LAD artery had been revascularized by a saphenous vein graft, her left ventricular ejection fraction remained as low as 10%?15%, leading to ventricular failure. Asystole and cardiovascular arrest then quickly developed, and despite aggressive cardiopulmonary resuscitation, she died. 一名38岁的妇女在两天前被丈夫踢到背部后，因背痛和疲劳加剧而住进了我们的门诊。在她的身体检查中，发现她背部肩胛骨之间有瘀斑。她面色苍白，双臂血压为80/60毫米汞柱，听诊时出现心动过速。在D1、aVL和V2导联中观察到ST段抬高，并伴有自心室节律加快（图1）。经胸超声心动图显示前间隔、心尖、基底中间隔和基底中前壁无活动，射血分数为20%。她立即被转移到导管插入术室。我们在通过右股动脉引入6-Fr鞘管后进行了冠状动脉造影。我们检测到左主动脉、左前降支（LAD）和旋支的夹层，起源于左冠状动脉（LMCA）的中部（图2和3，补充视频1、2）。在紧急心血管手术会诊后，她被转移到手术室。将隐静脉移植到左前降支远端。在心外膜血管的术中评估过程中，我们的心脏外科医生团队不打算在旋支上放置旁路移植物，因为它很薄且不占优势。由于患者在输注去甲肾上腺素和多巴胺后出现低血压，她被转移到心血管外科重症监护室，使用体外膜氧合器（ECMO）和主动脉内球囊泵（IABP）。在随访期间，尽管有积极的肌力和机械支持，她的血压仍然很低，约为60/40毫米汞柱。术后第二天，尽管患者的左前降支动脉已通过隐静脉移植物进行了血运重建，但其左心室射血分数仍低至10%~15%，导致心室衰竭。随后很快出现了心搏停止和心血管骤停，尽管进行了积极的心肺复苏，她还是去世了。
4.踢足球外伤导致冠状动脉夹层 参考文献：踢足球外伤导致冠状动脉夹层。Van Mieghem NM, van Weenen S, Nollen G, Ligthart J, Regar E, van Geuns RJ. Traumatic coronary artery dissection: potential cause of sudden death in soccer. Circulation. 2013;127(3):e280-e282. doi:10.1161/CIRCULATIONAHA.112.119982 杂志：著名杂志Circulation（JCR分区，Q1） 作者单位：Department of Interventional Cardiology, Thoraxcenter, Erasmus Medical Center, Room Bd 171, Gravendijkwal 230 3015 CE Rotterdam, The Netherlands. 简介：A 33-year-old male soccer player started to experience chest discomfort briefly after taking a blow from an opponent’s knee into his chest during a dribbling maneuver on the pitch. He completed the game but then consulted a referring hospital because of waxing and waning chest complaints irradiating to his left arm. The ECG demonstrated ST-T–segment changes compatible with inferoposterior ischemia (Figure 1). Cardiac enzyme markers were elevated. Echocardiography confirmed inferior wall hypokinesis. The patient was loaded with aspirin and clopidogrel. He subsequently underwent transradial invasive coronary angiography, which demonstrated Thrombolysis In Myocardial Infarction (TIMI) 2 flow in the right coronary artery and a dissection-suspect lesion in its proximal segment (online-only Data Supplement Movie I and Figure 2). Invasive imaging of the right coronary artery by means of optical coherence tomography confirmed mild atherosclerotic disease and unequivocally pointed toward dissection in the proximal segment surrounded by significant thrombus burden (Figure 3 and online-only Data Supplement Movie II). It is noteworthy that the size of the right coronary artery exceeded 5 mm in diameter. 一名33岁的男子足球运动员在球场上运球时，被对手膝盖击打胸部，随后开始短暂感到胸部不适。他完成了比赛，但随后去了转诊医院，因为左臂受到胸部不适的影响。心电图显示ST-T段变化与下空间缺血相容（图1）。心脏酶标记物升高。超声心动图证实下壁运动功能减退。患者服用阿司匹林和氯吡格雷。随后，他接受了经桡动脉有创冠状动脉造影，显示右冠状动脉中有心肌梗死溶栓（TIMI）2血流，近端有疑似夹层病变（仅在线数据补充电影I和图2）。通过光学相干断层扫描对右冠状动脉进行有创成像，证实了轻度动脉粥样硬化疾病，并明确指出近端节段夹层周围有明显血栓包围（图3和仅在线数据补充电影II）。值得注意的是，右冠状动脉的直径超过5毫米。
C is 5 mm proximal from the thrombus and shows a plaque rupture (arrow). 5.足球运动导致的冠状动脉夹层 参考文献：足球运动导致的冠状动脉夹层。Hazeleger R, van der Wieken R, Slagboom T, Landsaat P. Coronary dissection and occlusion due to sports injury. Circulation. 2001 Feb 27;103(8):1174-5. doi: 10.1161/01.cir.103.8.1174. PMID: 11222484. 杂志：大名鼎鼎Circulation。 作者单位：Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands. 简介：A 29-year-old man presented with heavy chest pain of 1 hour duration. Two months earlier, after a violent body check while playing American football, he had the same discomfort, albeit to a lesser degree, on slight exertion. Previously, he had been healthy, with no risk factors for coronary artery disease. Physical examination was unremarkable. The ECG showed an extensive acute anterior infarction. Nitroglycerin, tirofiban, and aspirin were administered intravenously, and an emergency coronary angiography was performed from the right radial artery (Figure 1). The left anterior descending artery was occluded proximally, and a large obtuse marginal branch showed a dissection-like intraluminal filling defect without obstruction. All other coronary arteries appeared normal. The occlusion was crossed with a guidewire, dilated, and stented (JOMED, 1633.5), with a good initial result. The dissection flap was left as it was. Pain and ST-segment elevation subsided quickly, and a moderate elevation of cardiospecific enzymes was found. Tirofiban was continued for 24 hours. Control coronary angiography 5 days later (Figure 2) showed a widely patent stent and a normal angiographic appearance of the obtuse marginal branch. After 30 days, the patient had no anginal complaints and felt well. 一名29岁男子出现持续1小时的剧烈胸痛。两个月前，在踢美式足球时进行了一次剧烈的身体运动后，他也出现了同样的不适，尽管程度较轻，只是轻微用力。 此前，他身体健康，没有患冠状动脉疾病的危险因素。 体格检查并不显著。心电图显示广泛急性前部梗死。静脉注射硝酸甘油、替罗非班和阿司匹林，并从右桡动脉进行紧急冠状动脉造影（图1）。左前降支近端闭塞，一个大的钝缘支显示出夹层状管腔内充盈缺损，无阻塞。所有其他冠状动脉均正常。用导丝交叉闭塞，扩张并支架固定（JOMED，1633.5），取得了良好的初步结果。解剖皮瓣保持原样。疼痛和ST段抬高迅速消退，发现心脏特异性酶中度升高。替罗非班持续24小时。 5天后的对照冠状动脉造影（图2）显示支架广泛开放，钝缘支的血管造影外观正常。30天后，患者没有心绞痛症状，感觉良好。
6.冠状动脉夹层刚发生时可能没有症状 参考文献：Blevins AJ, Repas SJ, Alexander BM, Siebenburgen C. Blunt traumatic coronary artery dissection: A case study. Trauma Case Rep. 2021;37:100594. Published 2021 Dec 23. doi:10.1016/j.tcr.2021.100594 杂志： Trauma Case Rep（JCR分区，无） 作者单位：Wright State University Boonshoft School of Medicine, 3640 Colonel Glenn Hwy, Fairborn, OH 45324, USA. 简介：A 38-year old female, with no significant past medical history, presented to a freestanding emergency department with complaints of severe chest pain and right shoulder pain. The patient was on an inner tube being pulled by a boat when the patient was tossed into the air and landed forcefully, hitting the face and chest on the water. The patient denied any initial loss of consciousness or gross chest pain. One hour later the patient developed abrupt onset severe right arm and neck pain that radiated to the back. The patient subsequently felt nauseated and then vomited. 一名38岁的女性，既往无重大病史，因严重胸痛和右肩疼痛被送往独立急诊科。患者被运动着的船甩在空中，脸和胸部砸在水面上。当时，患者没有严重的胸痛，神志清楚。一小时后，患者突然出现严重的右臂和颈部疼痛，并辐射到背部。患者随后感到恶心，然后呕吐。 Upon evaluation in the emergency department, basic laboratory results were obtained, only notable for a leukocytosis of 15.9 K/uL and a troponin of 0.079 ng/mL. Chest x-ray and right shoulder and humerus x-rays were normal. CT of head and cervical spine revealed no injuries. Initial ECG obtained at the time of arrival was a rate of 72 with ST elevation lateral leads with reciprocal changes. Repeat ECG was obtained 5 min later, showing a rate of 84, with anterolateral acute infarct, and a ST elevation myocardial infarction (STEMI) alert was activated (Fig. 1). Transport was called but additional imaging was obtained during the wait. CT with contrast of chest, abdomen and pelvis was obtained that showed no evidence for aortic dissection or solid organ injury. At that time, the patient was transferred to a level two trauma center for higher level of care for trauma evaluation, cardiothoracic surgery evaluation, and interventional cardiology. 在急诊科进行评估后，获得了基本的实验室结果，仅白细胞增多15.9 K/uL和肌钙蛋白0.079 ng/mL值得注意。胸部x光片、右肩和肱骨x光片正常。头部和颈椎的CT显示没有损伤。到达时获得的初始心电图的比率为72，ST段抬高侧导联具有相互变化。5分钟后获得重复心电图，显示发生率为84，伴有前外侧急性梗死，并激活ST段抬高型心肌梗死（STEMI）警报（图1）。调用了传输，但在等待过程中获得了额外的图像。胸部、腹部和骨盆的CT对比显示没有主动脉夹层或实体器官损伤的证据。当时，患者被转移到二级创伤中心，接受更高级别的创伤评估、心胸外科评估和介入心脏病学护理。
Upon arrival to the trauma center, a CTA chest with cardiac gated windows and CTA head and neck revealed no vascular injury or aortic dissection. A bedside transesophageal echocardiogram was obtained and showed anterior wall hypokinesis but no aortic dissection, as requested by cardiothoracic surgery. The decision was made to proceed with selective coronary angiography to rule out coronary artery disease, coronary occlusion, or coronary artery dissection. Upon selective angiography of left and right coronary artery and left heart catheterization, the patient was found to have an occluded distal LAD, likely due to thrombus embolization in setting of blunt chest trauma (Fig. 2). The patient underwent aspiration thrombectomy of the proximal LAD using an aspiration catheter, as well as percutaneous transluminal coronary angioplasty (PTCA) of distal LAD using 2 × 15 mm balloon, with decrease of stenosis from 100% to less than 10%. Heparin drip and aspirin were initiated following the procedure. 到达创伤中心后，带有心脏门控窗的CTA胸部和CTA头颈部显示没有血管损伤或主动脉夹层。根据心胸外科的要求，进行了床边经食道超声心动图检查，显示前壁运动障碍，但没有主动脉夹层。决定进行选择性冠状动脉造影，以排除冠状动脉疾病、冠状动脉闭塞或冠状动脉夹层。在对左、右冠状动脉进行选择性血管造影术和左心导管插入术后，发现患者远端左前降支闭塞，这可能是由于钝性胸部创伤中的血栓栓塞所致（图2）。患者使用抽吸导管进行了左前降支近端的抽吸血栓切除术，并使用2×15mm球囊进行了左后降支远端的经皮冠状动脉腔内成形术（PTCA），狭窄程度从100%降至10%以下。术后开始肝素滴注和阿司匹林。
We present a case of a 38-year-old female presenting with an LAD dissection after blunt chest trauma. 最终诊断：胸部钝性外伤导致的左前降支冠状动脉夹层。 7.胸部钝性创伤后4周发生急性心肌梗死而发现冠状动脉夹层 参考文献：Mahmod M, Wage R, Alpendurada F, Pennell DJ. Cardiovascular magnetic resonance of acute myocardial infarction following traumatic coronary artery dissection. J Cardiovasc Med (Hagerstown). 2013;14(9):669-672. doi:10.2459/JCM.0b013e32833dae93 杂志： J Cardiovasc Med (Hagerstown).（JCR分区，Q4） 作者单位：Cardiovascular Magnetic Resonance Unit, Royal Brompton Hospital, London, UK. masliza.mahmod@gmail.com 简介：Traumatic coronary artery dissection is a very rare cause of myocardial infarction. Occurrence of this condition late in the posttraumatic period is extremely uncommon. We present a case of a young patient with acute myocardial infarction 4 weeks after blunt chest trauma. Coronary angiography showed left anterior descending artery dissection as well as thrombus formation, and multiple small infarctions were shown by cardiovascular magnetic resonance. 创伤性冠状动脉夹层是导致心肌梗死的一种非常罕见的原因。这种情况在创伤后后期发生是极为罕见的。我们报告一例年轻患者在胸部钝性创伤后4周发生急性心肌梗死。冠状动脉造影显示左前降支夹层和血栓形成，心血管磁共振显示多处小梗死。 8.创伤性冠状动脉夹层可能不合并骨折等等 参考文献：Vyas V, Badrinath M, Szombathy T. Traumatic Right Coronary Artery Dissection as a Cause of Inferior Wall ST-Elevation Myocardial Infarction. Cureus. 2020;12(1):e6694. Published 2020 Jan 18. doi:10.7759/cureus.6694。创伤性右冠状动脉夹层致下壁ST段抬高型心肌梗死。 杂志：Cureus（JCR分区，Q1） 作者单位：Internal Medicine, State University of New York (SUNY) Upstate Medical University, Syracuse, USA. 简介：A healthy 41-year-old male with no past medical history apart from alcoholism and smoking presented with chest pain after a high-speed motor vehicle accident and steering wheel trauma to the chest. On admission, his vitals were stable and physical examination was unremarkable. EKG showed ST elevations in leads II, III and aVF consistent with inferior wall MI and troponin was elevated at 5.38 ng/ml (Figure 1). 一名健康的41岁男性，除酗酒和吸烟外，无既往病史，在高速机动车事故和方向盘胸部创伤后出现胸痛。入院时，他的生命体征稳定，身体检查无异常。心电图显示导联II、III和aVF的ST段抬高与下壁心肌梗死一致，肌钙蛋白升高至5.38 ng/ml（图1）。
Before any other diagnostic tests could be performed, the patient developed severe substernal chest pain and soon became confused. EKG showed a complete heart block causing hemodynamic instability that required immediate transcutaneous pacing. An urgent bedside echocardiogram showed right ventricular akinesia with no evidence of pericardial effusion or other structural injuries to the heart. The patient was urgently taken to the cardiac catheterization laboratory. Coronary angiography revealed a long intimal flap in the RCA resulting in a 99% stenosis of the vessel, without resolution on intracoronary nitroglycerin administration (Figure 2). The remaining coronaries were normal. 在进行任何其他诊断测试之前，患者出现了严重的胸骨下胸痛，并很快变得神志模糊。心电图显示完全的心脏传导阻滞导致血液动力学不稳定，需要立即进行经皮起搏。紧急床边超声心动图显示右心室活动不全，没有心包积液或其他心脏结构损伤的证据。病人被紧急送往心导管插入术实验室。冠状动脉造影显示RCA有一个长内膜瓣，导致99%的血管狭窄，冠状动脉内硝酸甘油给药未解决（图2）。剩下的冠状动脉是正常的。 He underwent percutaneous coronary intervention, with the subsequent deployment of four drug-eluting stents with improvement from initial 99% stenosis (TIMI 1flow) to final 0% stenosis with TIMI 3 flow (Figure 3). Further imaging showed no evidence of other forms of blunt trauma injury like a cardiac contusion, hemopericardium, hemothorax or pneumothorax. The patient was monitored in the cardiac ICU and once medically stable, was discharged on dual antiplatelet therapy and a beta-blocker. 他接受了经皮冠状动脉介入治疗，随后部署了四个药物洗脱支架，从最初的99%狭窄（TIMI1流量）改善到最终的0%狭窄（TIMI3流量）（图3）。进一步的成像显示没有其他形式的钝性创伤的证据，如心脏挫伤、心包积血、血胸或气胸。患者在心脏重症监护室接受监测，一旦病情稳定，就出院接受双重抗血小板治疗和β受体阻滞剂。 9.严重外伤导致的冠状动脉夹层 参考文献：Jiang T, Qian C, Wei G, Cheng L, Zheng W, Chen G. Case report: Fatal traumatic coronary artery dissection-an overlooked complication of chest fracture. Front Cardiovasc Med. 2023;10:1226129. Published 2023 Sep 5. doi:10.3389/fcvm.2023.1226129 杂志：Frontiers in Cardiovascular Medicine（JCR分区，Q2） 作者单位：Depatment of Cardiology, The Affiliated Hospital of Southwest Medical University, Luzhou, China.西南医科大学附属医院心内科，泸州。 简介：在这里，我们介绍了一个病例，患者从18米高处坠落后，肋骨和股骨多处骨折，随后持续胸痛。在最初的诊断检查后，医疗团队将患者的胸痛诊断为肋骨骨折，没有考虑心脏损伤的潜在原因。没有强调监测心肌酶和心电图的变化，这可能表明冠状动脉夹层。只有在随后的冠状动脉造影（CAG）和光学相干断层扫描（OCT）检查后，才确认夹层并使用支架进行治疗，逐渐缓解了患者的胸痛。
FIGURE 3. Coronary angiography of the patient. (A,B) The arrow showed a dissection in the left anterior descending artery, and no stenosis was seen in the left circumflex artery. (C) The right coronary artery was normal. (D) Coronary angiography was repeated after stenting, and no luminal stenosis was seen at the arrow, and the dissection was closed. 图3。患者的冠状动脉造影。（A，B）箭头显示左前降支有夹层，旋支左动脉未见狭窄。（C） 右冠状动脉正常。（D） 支架置入后重复冠状动脉造影，箭头处未见管腔狭窄，夹层闭合。
Upon admission, an ECG suggested QS pattern and ST-segment elevation in leads V1–V4, I, and aVL (Figure 1B). Cardiac ultrasound showed no obvious abnormalities. 入院时，心电图提示V1–V4、I和aVL导联出现QS模式和ST段抬高（图1B）。心脏超声检查无明显异常。
10.没有严重外伤，也可能出现冠状动脉夹层 参考文献：Raxwal B, Baisla P, Nath J. A Collaborative Case Report Utilizing ChatGPT AI Technology of Traumatic Right Coronary Artery Dissection Resulting in Inferior Wall ST-Elevation Myocardial Infarction. Cureus. 2023;15(3):e35894. Published 2023 Mar 8. doi:10.7759/cureus.35894 杂志：Cureus（JCR分区，Q1） 作者单位：Medicine, Access Health Care Physicians, Zephyrhills, USA. 简介：本病例报告介绍了一名67岁男性的病例，他在一次机动车事故后因胸痛和心电图显示下壁ST段抬高型心肌梗死而被送往医院。进一步的成像显示C2右侧和左侧第12肋骨未移位性骨折。冠状动脉造影显示右冠状动脉远端有夹层。患者服用肝素并接受右冠状动脉支架置入术。患者在重症监护室接受任何创伤后并发症的监测，并对颈椎骨折进行保守治疗。
11.冠状动脉夹层导致心肌梗死 参考文献：Yoshida C, Yamamoto H, Kato C, Takaya T. Acute myocardial infarction due to traumatic coronary artery dissection: conflicts with thrombotic and bleeding pathologies. Eur Heart J Case Rep. 2023;7(3):ytad119. Published 2023 Mar 9. doi:10.1093/ehjcr/ytad119 杂志：（JCR分区，Q3） 作者单位：Division of Cardiovascular Medicine, Hyogo Prefectural Harima-Himeji General Medical Center, 3-264 Kamiya-cho, Himeji 6708560, Japan. 简介：一名74岁的男子是一起机动车事故的受害者，他经历了与多发伤相关的出血性休克（血压，79/47 mmHg；心率，105 b.p.m.）。心电图显示下导联ST段抬高（图1E）。在对其肝损伤进行紧急经导管动脉栓塞止血后，不含抗凝剂（肝素）的冠状动脉造影（CAG）显示右冠状动脉中/远端（RCA）模糊和闭塞，提示急性冠状动脉综合征[ST段抬高型心肌梗死（STEMI）]。1个月后的冠状动脉造影显示RCA的冠状动脉血栓尺寸显著减小，光学相干断层扫描显示多处内膜夹层，被诊断为局灶性创伤性冠状动脉夹层（图1H-K）。
12.缺乏急性冠状动脉综合征的冠状动脉夹层 参考文献：Son SA, Lee SC, Lee E, Lee JH. Traumatic coronary artery dissection misdiagnosed as stress-induced cardiomyopathy in a patient with multiple trauma. Trauma Case Rep. 2022;42:100698. Published 2022 Oct 4. doi:10.1016/j.tcr.2022.100698 杂志：Trauma Case Rep（JCR分区，无） 作者单位：Department of Thoracic and Cardiovascular Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, 130 Dongdeok-ro, Jung-gu, Daegu, Republic of Korea. 简介：我们报告一例42岁男性从3米高处坠落后出现心电图异常和心肌酶升高的病例。由于缺乏急性冠状动脉综合征的临床症状，该患者被误诊为应激性心肌病。随后，患者通过冠状动脉造影被诊断为创伤性冠状动脉夹层，并通过血管内超声（IVUS）证实了创伤的相关性。
(A) Chest CT angiography showing complete occlusion of long segment in the proximal left anterior descending (LAD) artery (white arrow). (B) Intravascular ultrasonography image showing a large amount of hematoma (arrowhead) that compressed the true lumen of proximal LAD. （A） 胸部CT血管造影术显示左前降支（LAD）近端长段动脉完全闭塞（白色箭头）。（B） 血管内超声图像显示大量血肿（箭头）压迫左前降支近端的真实管腔。 13.胸部钝性创伤后出现右冠状动脉夹层 参考文献：Paparoupa M, Conradi L, Warncke ML, et al. Blunt traumatic right coronary artery dissection presenting with second-degree atrioventricular block and late-onset severe cardiogenic shock. BMC Cardiovasc Disord. 2022;22(1):341. Published 2022 Jul 30. doi:10.1186/s12872-022-02784-6 杂志：BMC Cardiovasc Disord（JCR分区，Q3） 作者单位：Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr.52, 20246, Hamburg, Germany. 简介：我们报告了一例16岁患者在胸部钝性创伤后出现RCA（右冠状动脉）夹层的病例，该患者入院时最初表现为二度房室传导阻滞，为孤立表现。没有典型的心电图表现，如ST段变化或病理性Q波。连续超声心动图排除节段性运动异常、心包积液或右心室应变。然而，几小时后，一项补充的计算机断层扫描冠状动脉造影显示了这种潜在的致命情况。
Contrast-enhanced CT and CTCA showing pericardial effusion, right heart strain and proximal RCA dissection. A Contrast-enhanced CT showed a progressive pericardial effusion (white arrows). B, C Massive right heart strain and inferoseptal myocardial infarction (white arrows). D Coronary CT angiography revealed a short proximal discontinuation (white arrows) of the RCA, highly suggestive of dissection. 对比增强CT和CTCA显示心包积液、右心应变和近端RCA夹层。增强CT显示进行性心包积液（白色箭头）。B、 C右心大面积劳损和下间隙心肌梗死（白色箭头）。D冠状动脉CT血管造影术显示RCA近端短暂中断（白色箭头），高度提示剥离 14.吵架导致的创伤性冠状动脉夹层 参考文献：Bayraktaroğlu S, Nawaz Nasery M, Foladi N. Traumatic left main coronary artery dissection in a young adult following blunt chest trauma - A case report. Radiol Case Rep. 2022;17(4):1190-1193. Published 2022 Feb 4. doi:10.1016/j.radcr.2022.01.016 杂志：Journal of Radiology Case Reports（JCR分区，Q3） 作者单位：Department of Radiology, Thoracic imaging, Ege University Hospital, Faculty of Medicine, Izmir, Turkey. 简介：A 29-year-old male patient was brought to the emergency department with persistent chest pain following an altercation. However, physical examination was normal. No injuries were detected in the body. There was no sign of injuries to the chest wall during physical examination. Due to the persistent chest pain, he was referred to the cardiology department for further work-up. Initial ECG demonstrated elevation of 1 mm ST-segment in aVR and aVL leads as well as 1 mm ST-segment depression in D2, D3, aVF leads. (ECG image not available) For further assessment, cardiac enzymes were ordered to ascertain the diagnosis of acute cardiac injury. The result of enzymes demonstrated a significant rise in the cardiac troponins. For further evaluation and definite diagnosis coronary CT angiography (128-slice Siemens) was performed demonstrating a long segment intramural hematoma at the left main coronary artery with significant luminal narrowing denoting coronary artery dissection. Figs. 1 and 2 Afterward, the patient was referred for coronary angiography, demonstrating tapered luminal stenosis at the left main coronary artery. Fig. 3 However, distal vascular opacification was present. After receiving the radiology report, the patient was lost to follow up. 一名29岁的男性患者因口角后持续胸痛被送往急诊科（作者认为争吵导致胸部钝性损伤）。不过，身体检查正常，没有发现任何外伤。在体检过程中，胸壁没有受伤的迹象。由于持续的胸痛，他被转诊到心脏科做进一步的检查。初始心电图显示aVR和aVL导联ST段抬高1mm，D2、D3和aVF导联ST节压低1mm。（心电图图像不可用）为了进一步评估，要求使用心脏酶来确定急性心脏损伤的诊断。酶的结果显示心肌肌钙蛋白显著升高。为了进一步评估和明确诊断，进行了冠状动脉CT血管造影术（128层西门子），显示左冠状动脉主干处有长段壁内血肿，管腔明显狭窄，表示冠状动脉夹层。图1和图2之后，患者被转诊进行冠状动脉造影，显示左冠状动脉主干管腔狭窄。图3然而，存在远端血管混浊。在收到放射学报告后，患者失去了随访的机会。
Fig. 1. (A-C) oblique and axial contrast enhanced ECG gated CT angiographic views demonstrate intramural hematoma and long tapered luminal narrowing of proximal left main coronary artery (orange arrows); features of coronary artery dissection. 图1。（A-C）斜向和轴向增强心电图门控CT血管造影视图显示壁内血肿和左近端主冠状动脉的长锥形管腔狭窄（橙色箭头）；冠状动脉夹层的特点。
Fig. 2. 3D VRT image of the left main coronary artery showing diffuse narrowing (orange arrow); normal appearing left anterior descending artery (green arrow), and left circumflex artery (red arrow). 图2。显示弥漫性狭窄的左主冠状动脉的3D VRT图像（橙色箭头）；正常出现的左前降支（绿色箭头）和左旋支（红色箭头）。 15.冠状动脉夹层可能没有胸痛 参考文献：Abellas-Sequeiros M, Pardo Sanz A, Sanchez-Recalde A, Sanmartin-Fernandez M. Traumatic coronary artery dissection with total occlusion of left descending coronary artery: to stent or not to stent. Eur Heart J. 2021;42(45):4701. doi:10.1093/eurheartj/ehab477 杂志：European Heart Journal （JCR分区，Q1） 作者单位：Servicio de Cardiologia, Hospital Universitario Ramon y Cajal, Carretera de Colmenar Viejo, 9100, CP 28034, Madrid, Spain. 简介：A 21-year-old man was admitted at the Emergency Department after a motorcycle accident with frontal crash into a tree. A computerized tomography scan confirmed Le Fort III fracture, hepatic laceration, and haemoperitoneum. An electrocardiogram was performed as part of the initial evaluation, showing ST-segment elevation in leads I, aVL, V1, and V2, with ST depression in inferior leads (Panel A). The patient denied chest pain. Transthoracic echocardiogram showed septal hypokinesia, with preserved ejection fraction. Troponin was positive (Tn I 20.2 ng/mL). Coronary angiography was performed, showing ostial left anterior descending artery occlusion (Panel B and Supplementary material Online, Video S1), with Rentrop 2 coronary collaterals. Intravascular ultrasound (IVUS) interrogation revealed an occlusive coronary dissection with thrombosis of the false lumen (Panel C and Supplementary material Online, Video S2). Considering the mechanism of the occlusion, the total length of the occluded segment and the potential bleeding risk associated to the fractures and liver laceration, a free-stent strategy was chosen, in order to avoid dual antiplatelet therapy. Accordingly, a cutting balloon 3 × 10 mm was advanced through the occlusion and several inflations at 6–8 atm were performed, restoring TIMI III flow (Panel D and Supplementary material Online, Video S3). The proximal vessel was treated with an AngioSculpt balloon 3.5 × 15 mm. Post-IVUS pullback showed good luminal area of the true lumen (Panel E and Supplementary material Online, Video S4). 一名21岁男子因摩托车正面撞向一棵树而在急诊科入院。计算机断层扫描证实Le Fort III骨折、肝脏撕裂伤和腹膜出血。作为初步评估的一部分，进行心电图检查，显示I、aVL、V1和V2导联ST段抬高，下导联ST段压低（图A）。病人否认胸痛。经胸超声心动图显示室间隔运动功能减退，射血分数保持不变。肌钙蛋白呈阳性（Tn I 20.2 ng/mL）。进行冠状动脉造影，显示左前降支窦口闭塞（面板B和在线补充材料，视频 S1），与Rentrop 2冠状动脉侧支。血管内超声（IVUS）询问显示闭塞性冠状动脉夹层伴假腔血栓形成（面板C和在线补充材料，视频 S2）。考虑到闭塞的机制、闭塞段的总长度以及与骨折和肝撕裂伤相关的潜在出血风险，选择了自由支架策略，以避免双重抗血小板治疗。因此，将一个3×10 mm的切割球囊推进通过封堵，并在6-8个大气压下进行多次充气，恢复TIMI III流量（面板D和在线补充材料，视频 S3）。用AngioSculpt球囊3.5×15 mm治疗近端血管。IVUS后回撤显示真实管腔的管腔面积良好（图E和在线补充材料，视频 S4）。
16.交通事故与冠状动脉夹层.没有骨折 参考文献：Rojas ER, Gimple LW, Morsy M, Villines TC. Early Recanalization of a Traumatic Coronary Artery Dissection With Medical Therapy Alone. JACC Case Rep. 2020;2(15):2299-2303. Published 2020 Dec 16. doi:10.1016/j.jaccas.2020.09.040 杂志： JACC Case Rep（JCR分区，无） 作者单位：Cardiovascular Division, University of Virginia School of Medicine, University Hospital, Charlottesville, Virginia, USA. 简介：A 33-year-old man was admitted to the trauma service after a high-speed motor vehicle collision. He had intimal injuries in the anterior wall of the descending thoracic aorta (Figure 1) and right subclavian arteries that were managed conservatively. He was safely discharged home with interval resolution of his injuries on follow-up imaging. 一名33岁的男子在高速机动车相撞后被送入创伤科。他在降胸主动脉前壁（图1）和右锁骨下动脉有内膜损伤，这些损伤得到了保守治疗。他被安全出院回家，后续成像显示他的伤势区有间断缓解。
Seven months later, the patient presented to the emergency department of a non–percutaneous coronary intervention (PCI)-capable center for new-onset chest discomfort after having a second motor vehicle accident. He was driving a four-wheel all-terrain vehicle when he hit an unknown object, flew over the handlebars, and woke up with the vehicle on top of him. The following day (∼30 h later), he experienced new-onset chest discomfort radiating to his left arm that prompted him to seek medical attention. 七个月后，患者因第二次机动车事故后新发胸部不适，被送往非经皮冠状动脉介入治疗中心急诊科。他驾驶一辆四轮全地形车时，撞上了一个未知物体，从车把上飞过，醒来时车就在他身上。第二天（～30小时后），他出现了新发的胸部不适，辐射到左臂，这促使他寻求医疗护理。 The left anterior descending artery (LAD) was occluded at the ostium flush with findings believed to be consistent with coronary dissection (linear densities) and areas with apparent thrombosis (Videos 1 and 2). 左前降支（LAD）在窦口处闭塞，其结果被认为与冠状动脉夹层（线性密度）和明显血栓形成区域一致（视频1和2）。 最终诊断：Traumatic Coronary Artery Dissection，外伤性冠状动脉夹层。 17.机动车事故后急性左前降支和右冠状动脉夹层 参考文献：Pandey Y, Owen B, Birnbaum G, et al. Multivessel Traumatic Coronary Artery Dissection After a Motor Vehicle Accident With Successful Percutaneous Coronary Intervention. JACC Case Rep. 2020;2(15):2295-2298. Published 2020 Nov 4. doi:10.1016/j.jaccas.2020.09.021 杂志：JACC Case Rep（JCR分区，无） 作者单位：Baylor College of Medicine, Ben Taub General Hospital, Houston, Texas, USA. 简介：我们报告了一起机动车事故后急性左前降支和右冠状动脉夹层的病例。肌肉骨骼损伤掩盖了心脏症状。心电图和床边超声心动图显示了心脏病理，这促使紧急进行冠状动脉造影和干预。 18.冠状动脉夹层造成的心脏骤停 参考文献：Kucharski F, Piwowarczyk S, Wasilewska M, Filipczyk A. Sudden cardiac arrest due to traumatic coronary artery dissection. Case report. Anaesthesiol Intensive Ther. 2021;53(2):190-194. doi:10.5114/ait.2021.104308 杂志：Anaesthesiol Intensive Ther.（JCR分区，Q2） 作者单位：Anesthesiology and Intensive Care Students' Scientific Circle, Medical University of Gdańsk, Poland. 简介：由于冠状动脉夹层造成的心脏骤停。 A 24-year-old patient was admitted to the emergency department to treat the injuries sustained as a result of a traffic accident. The victim was the driver of a passenger car that collided with an excavator at high speed. On admission, the patient was conscious, sleepy, with respiratory insufficiency . One hour and 20 minutes after admission to the emergency department, the patient developed a sudden cardiac arrest due to ventricular fibrillation. 一名24岁的患者因交通事故受伤，被送入急诊室接受治疗。受害者是一辆客车的司机，该客车与一辆挖掘机高速相撞。入院时，患者意识清醒，嗜睡，呼吸功能不全。入院1小时20分钟后，患者因心室颤动出现心脏骤停。 19.另类“创伤性”冠状动脉夹层 参考文献：Ahmed MA, Arnous S. Traumatic right coronary artery dissection. BMJ Case Rep. 2021;14(2):e221287. Published 2021 Feb 4. doi:10.1136/bcr-2017-221287 杂志：（JCR分区，N） 作者单位：Cardiology Department, University Hospital Limerick, Dooradoyle, Ireland mod3llam@live.com. 简介：In our case, the potential aetiology of the right coronary artery dissection is secondary to 'the traumatic impact’ of the large calcified aortic valve mass into the right coronary artery。在我们的病例中，右冠状动脉夹层的潜在病因是继发于大的钙化主动脉瓣肿块进入右冠状动脉的“创伤性影响”.
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