Contribution of guidance by optical coherence tomography (OCT) in rescue management of spontaneous coronary artery dissection

Spontaneous coronary artery dissection (SCAD) is a rare pathology with a poor prognosis, affecting young patients, often peripartum women, without cardiovascular risk factors.1 The SCAD management remains controversial. In the case of haemodynamic instability with coronary occlusion, rescue percutaneous intervention may be required but still challenging.2 A 43-year-old nurse was admitted for acute myocardial infarction complicated by cardiogenic shock. Emergent angiography revealed a total occlusion of the left anterior descending (LAD) coronary artery. Recanalization was complex, finally achieved utilizing a guidewire (GW1) introduced until a diagonal branch, providing a TIMI-2 coronary flow. The presence of linear intraluminal haziness suggested a diagnosis of SCAD. Considering the haemodynamical instability and EKG persistent ST-elevation, we discussed stent implantation to fix the suspected intimal tear. We first performed OCT imaging that provided diagnosis of SCAD and showed GW1 positioned outside of the true lumen (Panel A). We introduced a second GW2 progressing easily until distal LAD, but worsening coronary flow.