We would like to thank Dario Buccheri for the interest shown in our article “Spontaneous coronary artery dissection: a single-center case series and literature review”.1

We reported an interesting case series of spontaneous coronary artery dissection (SCAD) from our center, in which we presented the prevalence of SCAD in our cohort, its form of presentation, patient characteristics, how we managed the condition and its prognosis.

As the author pointed out, SCAD remains an underdiagnosed entity.2 Therefore, it is crucial to have a high level of clinical suspicion, recognize some particular features characteristic of this entity, be familiar with all angiographic patterns and systematically use intracoronary imaging.

We analyzed with great interest the scoring system proposed and tested by Buccheri et al.,3,4 which scores clinical and angiographic variables that raise the suspicion of SCAD and favors the use of optical coherence tomography or intravascular ultrasound to confirm the diagnosis. We think that it could be a useful and practical tool for diagnosis, although it still needs statistical validation in a larger cohort. Although invasive treatment is suggested in the score and in the letter, this kind of strategy is based on case reports and experience in short case series.5,6 Percutaneous treatment of SCAD may carry non-negligible risks, such as secondary iatrogenic dissection, guidewire passage into the false lumen, proximal or distal false lumen propagation during stent deployment, persistent distal dissection, major side branch occlusion or flow limitation, and subacute or late stent malapposition due to intramural hematoma reabsorption.7,8 Indeed, technical failure of percutaneous coronary intervention may occur in up to half of patients with SCAD.9 Dr. Buccheri proposed that in this setting, bioresorbable vascular scaffolds (BVS) might be an interesting therapeutic tool because they allow for SCAD sealing and healing, theoretically with subsequent restoration of the morphological and functional characteristics of the coronary segment treated. This option could be of great importance in cases of long SCAD requiring multiple overlapping permanent stents, which are associated with a high rate of adverse events at follow-up. However, compared with newer drug-eluting stents, BVS are associated with higher risk of device thrombosis and target lesion failure,10 and thus they would probably require longer clinical follow-up and intracoronary imaging control to assess vascular repair and device failure.

In fact, the optimal treatment strategy remains controversial and undetermined, as no randomized trials comparing conservative with revascularization strategies have been carried out. Nevertheless, there is good evidence that the majority of SCAD will first stabilize and then heal completely over time, if managed conservatively.9,11–13 It is recognized that revascularization in SCAD is challenging, because of the presence of an underlying disrupted and friable vessel wall, not infrequently leading to a suboptimal outcome.9,12,14 In stable patients, i.e. those in whom revascularization is not required, a conservative strategy is generally accepted.15,16 Given the current concern about this condition, the European Society of Cardiology has created a SCAD registry, which we expect will help us to improve our knowledge about this subject.