Abstract
BACKGROUND: Spontaneous coronary artery dissection (SCAD) is an under-recognized cause of acute coronary syndrome (ACS), particularly in younger patients without conventional cardiovascular risk factors. Accurate differentiation of recanalized thrombi is essential to avoid inappropriate treatment. CASE SUMMARY: Patients with ACS who underwent intracoronary imaging between January 2024 and June 2025 were retrospectively analyzed. Conventional angiography frequently misclassifies lesions. Optical coherence tomography (OCT) provides diagnostic clarity by identifying intramural hematoma and false lumen morphology in true SCAD, confirming recanalized thrombi through multiple intraluminal channels with preserved vessel walls, or ruling out SCAD by demonstrating fibrocalcific atherosclerosis. These findings directly impact therapeutic decisions, ranging from conservative management to revascularization. DISCUSSION: OCT consistently outperformed angiography in resolving the diagnostic ambiguity in suspected SCAD and thrombus, preventing misdirected interventions, and guiding pathology specific therapies. CONCLUSIONS: OCT is indispensable in suspected SCAD, refining diagnosis, enabling individualized treatment strategies, and improving patient outcomes.