Organized Thrombus Masquerading as Spontaneous Coronary Artery Dissection: A Set of Two Cases

Background Spontaneous coronary artery dissection (SCAD) often impacts young women who lack traditional risk factors. Diagnosing SCAD can be challenging due to its diverse angiographic presentations and resemblance to other conditions, such as organized thrombus. Case Summary We present two cases involving middle-aged male smokers, each experiencing chest pain lasting over 12 hours. Both patients exhibited ST-segment elevation in the anterior leads on ECG, anterior wall hypokinesia, and an LVEF of 40% on 2D echocardiography. Immediate coronary angiography revealed dye staining and multiple radiolucent lumens in the LAD, indicative of SCAD. Optical coherence tomography (OCT) identified an organized thrombus with a distinctive “Swiss cheese” pattern, differing from the usual radiolucent false lumen associated with SCAD. Both patients were successfully treated with PCI, including thrombus aspiration and stent placement. Take-home message Relying solely on angiography for SCAD diagnosis may overlook organized thrombus. Redefining SCAD criteria and utilizing multimodal imaging like OCT in all cases is essential.