Male patient, 35 years oldHistory: Hypertension, CKD for 1 year because of  IgA glomerular disease, currently being treated with Coversyl 5mg, Medrol 16 mg. No history of chest injuries, smoking, or drugs.Clinical presentation at admission: Chest angina, sweating in pain course, vomiting + NYHA III dyspnea 10 hours agoVital signs: Blood pressure 120/80 mmHg, Heart rate: 95 beats/minute,Signs of visit: Unremarkable

Bedside emergency echocardiography:Suspected hypokinesis of 1/3 of the interventricular septum toward the apex and apical regionThe left ventricular chamber is not dilated, and the left ventricular systolic function is within normal limitsCreatinin: 200 mcmol/lTroponin T hs: 777.9 -->4244 ng/lGOT/GPT: 183/87 U/LBlood gas test: PH 7.29.   PCO2: 42 mmHg    PO2: 96 mmHg     Lactat: 5 mmol/l

Angiogram: SCAD type 1 at p-LAD caused TIMI 1 flow, Lcx seems normal. Likely SCAD at p-RCA, TIMI 3 flow. Maybe Thombus?

EBU 3.5. Right radial artery. wire: BMW  Runthrough. we perform slightly pre-dilate the deployed stent at LAD. Result: Good LAD TIMI Flow  STOP. We plan to perform 2nd coronary angiography after a few days. Right after PCI: Stable hemodynamic, symptoms relieved. After 48 hours: recurrent Chest pain, and dizziness. ECG: BAV III. Indications: Temporary pacemaker + Re- angiography. Result: LAD stent is still good. The RCA vessel wall is more 'solid' and the flow is still good ( better than 2 days ago) but the vessel wall is not as smooth then we performed IVUSIVUS image: RCA vessel wall hematoma + Ruptured atherosclerotic plaque --> PCI RCA with DES 4.0X 38 mm, TIMI 3 Flow. IVUS after stenting: No dissection, no malposition, good expansion. After 2nd PCI: Relieved chest pain. Heart rate is 90 beats/minute. Blood pressure 120/80 mmHg (Noradrenaline 0.1 ug/kg/pg).The patient is stable and discharged after 5 days

1. SCAD is rare but the incidence tends to be increased and dissection of multiple vessels occurs in 9-23%2. SCAD management: mostly conservation therapy. PCI can increase widespread dissection and be used for suitable patients: unstable hemodynamic/ arrhythmia, proximal dissection, or TIMI flow <=2… CABG is also another choice if LM or proximal dissection, after failed PCI, complications after attempted PCI, or refractory ischemia despite optimal medical therapy.3. PCI Technique aspects: Avoid pushing the catheter deeply, avoid vigorous injection of contrast medium, place extra 5-10mm stents at both ends, and direct stenting.