Optical Coherence Tomography: Case Series and Review on Differentiating Spontaneous Coronary Artery Dissection From Recanalized Thrombus.

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  Visual Summary. Case Series and Review on Differentiating Spontaneous Coronary Artery Dissection From Recanalized Thrombus OCT clarifies the pathology by revealing hallmark SCAD features vs the channel-like pattern of recanalized thrombi, thereby guiding appropriate conservative or interventional management. ACS = acute coronary syndrome; OCT = optical coherence tomography; SCAD = spontaneous coronary artery dissection.

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  Figure 1. Case 1: Angiogram In 2018 at another center, (A) suspected spontaneous coronary artery dissection (SCAD) in the right coronary artery (RCA). (B) Left circumflex artery (LCX) and (C) likely missed SCAD in left anterior descending artery (LAD). In 2024 at our center, interpreted as SCAD of the (D) proximal LAD with (E) extensive SCAD (red arrow) of large nondominant LCX with OMM and (F and G) extensive SCAD (red arrow) of the RCA from the ostium to PDA and PLV. OMM = obtuse marginal - major; PDA = posterior descending artery; PLV = posterior left ventricular artery.

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  Figure 2. Case 1: Pre- and Post-PCI High-Definition Intravascular Ultrasound of the RCA (A) Multiple blood-filled lumens (yellow arrows) noted from the proximal RCA to the PDA. (B) Post- percutaneous coronary intervention (PCI) intravascular ultrasound, well-expanded stents, and the healthy distal segment of the PDA. Abbreviations as in Figure 1.

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  Figure 3. Case 1: Prestenting Optical Coherence Tomography of the LAD and LCX (A) LAD: intramural hematoma (∗), intimal rupture (blue arrow), and lumen being pushed inward. (B) LCX showing a second lumen forming toward 9 o’clock to 3 o’clock (∗) and the true lumen (#) being pushed toward 3 o’clock to 6 o’clock; clear intimal tears (blue arrow) are noted. Abbreviations as in Figure 1.

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  Figure 4. Case 2: Initial Coronary Angiography Image Projection: LAO cranial (A) and RAO (B) showing luminal irregularities (#) that were initially interpreted as spontaneous right coronary artery dissection. The angiogram depicts an abrupt luminal caliber change, which can be ambiguous and mimicked by an organized thrombus. LAO = left anterior oblique; RAO = right anterior oblique.

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  Figure 5. Case 2: Prestenting OCT of the Right Coronary Artery (A) Longitudinal mode optical coherence tomography (OCT) demonstrating the complex channelized nature of the thrombus. (B-G) Magnified OCT view showing clear delineation of the channels (∗) within the thrombus and intact internal elastic lamina (red arrow) and media (open arrows) behind the mass, confirming the intraluminal nature of the lesion rather than dissection within the vessel wall. The intact internal elastic lamina tracing behind the second lumen confirms it is within the vessel cavity, suggesting a thrombus rather than spontaneous coronary artery dissection (SCAD); the edge of the thrombus (#) can be traced back in to a secondary lumen (@) due to recanalization of the thrombus (not to be confused with a false lumen of SCAD).

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  Figure 6. Case 3: Patient Angiogram and OCT of LAD (A) LAO cranial view with suspected type 3 SCAD of the mid RCA (∗). (B) RAO view with suspected SCAD of the RCA (∗) (C-E). LAD with a suspicious filling defect in the mid LAD (type 1 SCAD/recanalized thrombus) with delayed dye clearance (red arrow) and suspected type 3 SCAD in the LCX/OM (yellow arrow) (F). Final PCI to LAD results (G and H). LAD lumen pushed inward; false lumen indicated with # (I). OCT L-mode: true lumen pushed inward by false lumen (#). Abbreviations as in Figures 1, 4, and 5.

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  Figure 7. Case 4: Patient Angiogram and OCT of the LAD (A) Angiogram showing the LAD, suggestive of a thin tubular lumen with sharp edges, highly suspicious for type 2A/3 SCAD in the LAD. (B) OCT revealing a fibrocalcific plaque with a minimal luminal area of 0.89 mm2 and no features suggestive of an SCAD. Abbreviations as in Figures 1 and 5.

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  Figure 8. Evidence-Based Diagnostic Workflow ACS = acute coronary syndrome; other abbreviations as in Figures 1 and 5.