Author + information
- Gunasekaran Sengottuvelu, MD, DM∗ ( and )
- Ravindran Rajendran, MD, DM
- ↵∗Cardiology Department, Apollo Hospitals, 21 Greams Lane, Off Greams Road, Chennai 600006, India
We read the letter from Dr. Cade and colleagues in response to our paper (1) with great interest and would like to share our views. Optical coherence tomography (OCT) with very high resolution can be considered the gold standard (2) to diagnose coronary artery dissection, but in a given case it may be limited by the residual blood, shadowing, or insufficient penetration and intravascular ultrasound may be complementary (3). Demonstration of an intimo-medial membrane with double lumen appearance or an intramural hematoma with or without an entry point on OCT is important for diagnosis of spontaneous coronary artery dissection (4). In the case we presented, our angiographic diagnosis was diffuse organized intraluminal thrombus. This patient presented a few weeks after acute coronary syndrome and hence the typical angiographic contrast staining may not be seen. OCT runs showed areas of clear dissection flap with intramural hematoma and areas of organized thrombus both intraluminal and in the subintimal space (Figures 1A and 1B, Online Video 1). There are also areas of organized intraluminal thrombus with recanalization in other parts of the vessel. In their letter, Jamil et al. have brought out an important point for discussion as both organized intraluminal thrombus and dissection may mimic each other in OCT, and a practitioner needs to consider both in the differential diagnosis and both may be seen in the same patient. The best way to differentiate between them is to study the moving frames of the OCT run to understand its continuity. The other factor to be considered in a possible dissection flap is the documentation of discontinuity within the layers of vessel wall with intramural hematoma. Both these findings in this case favor a diagnosis of spontaneous coronary artery dissection.
Spontaneous coronary artery dissection has been shown to have a high tendency for spontaneous healing, and the process would obviously involve thrombus formation and organization within the intramural hematoma. It is prudent to note that this case was studied a few weeks after acute coronary syndrome and organized thrombus within the intramural hematoma are seen in various stages of natural healing.
For the accompanying video, please see the online version of this paper.
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