LAUSR

is performed in clinically unstable patients, those who have ongoing ischemia, and stable patients with severe 2-vessel proximal or left main dissection. The mechanism of reoccurring dissection in our case, due to the unavailability of intracoronary imaging, will remain speculative. First, it is possible that during first procedure, the proximal edge of the implanted stent may have landed on an intramural hematoma causing expansion of dissection, even though no evidence of this was present on control angiography. Alternatively, the second dissection may have been a de novo event. Intracoronary imaging would have certainly given insights into the mechanism of dissection (8). During the first presentation, the patient was relatively low risk, with a calculated GRACE score of 67 points. The distal flow was well preserved, suggesting that conservative management approach could have been the strategy of choice. It is important to remember that in SCAD, ischemia is not the only cause of chest pain, vessel dissection itself may be the cause of pain; thus, ischemia as the cause of pain should be carefully considered. Similarly, using troponin elevation as a criterion for intervention is questionable as ACS was the main clinical presentation of SCAD in trials, which have found conservative management safe (5). On the second presentation, indication for revascularization was clearer as large myocardial area was at risk, and angiographically, distal flow was impaired. Finally, when decision is made to proceed with revascularization via PCI, we believe that intracoronary imaging can be a valuable tool in guiding the procedure (8).