Answer to the last #DiagnosticDilemma
A 42-year-old woman with acute myocardial infarction

The correct answer is C. The abnormal appearance of the external iliac artery is due to a fibromuscular dysplasia (FMD) evident as a ‘string-of-beads’ appearance in a patient with spontaneous coronary artery dissection (SCAD).

Major takeaways:-
• SCAD is caused by the formation of coronary intramural haematoma often presenting as acute coronary syndrome. SCAD typically occurs in younger, mainly female patients compared with atherothrombotic coronary syndromes. There is a strong association between SCAD and FMD.

• Intravascular ultrasound or coronary optical coherence tomography can confirm SCAD by demonstration of intramural haematoma, but neither was performed in this case.

• FMD is a non-atherosclerotic arteriopathy most commonly affecting the renal and cerebrovascular (carotid and vertebral) arteries. Figure 1B shows multifocal FMD evident as alternating stenoses and dilatations.

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