Juxtaposition of urgent angioplasty results in spontaneous coronary artery dissection: a case report of fresh vs. organized intramural haematoma

BACKGROUND: Coronary intramural haematoma from spontaneous coronary artery dissection (SCAD) presents as an acute coronary syndrome, usually in young or middle-aged female patients. Conservative management in the absence of ongoing symptoms is best practice, and the artery eventually heals fully. CASE SUMMARY: A 49-year-old female presented with a non-ST elevation myocardial infarction. Initial angiography and intravascular ultrasound (IVUS) demonstrated typical intramural haematoma of the ostial to mid left circumflex artery. Initial conservative management was selected, but the patient developed further chest pain 5 days later and with worsening electrocardiogram changes. Further angiography was carried out demonstrating near-occlusive disease with organized thrombus in the false lumen. The angioplasty result from this is juxtaposed with another acute SCAD case on the same day with fresh intramural haematoma. DISCUSSION: Reinfarction is a common occurrence in SCAD, and little is known about how to predict it. These cases demonstrate the appearance on IVUS of fresh vs. organized thrombus and the relative angioplasty result in each case. Follow-up IVUS due to ongoing symptoms in one patient demonstrated significant stent malapposition, not apparent at the index intervention, in all likeliness due to intramural haematoma regression.