A case with complicated management and difficult decision-making is presented. A patient with history of type A aortic dissection and residual dilatation of the descending aorta up to 60 mm is admitted for acute coronary syndrome without ST elevation. Coronary angiography reveals a marked coronary ectasia and perfusion defects of unclear origin. Thrombosis or fake images due to flow reduction? Assuming that it could be caused by thrombosis the patient is treated with anticoagulant therapy and the coronary angiography is repeated after two months. This second study shows complete clearing of imaging findings, confirming the thrombotic origin. At this stage considerations are taken so as to plan a chronic treatment for the patient? There is no scientific evidence regarding the treatment for coronary ectasia and this is a high-risk patient because of his aortic dissection history. Finally it is empirically decided to indefinitely keep anticoagulant therapy. After two years and six months of follow-up there has been no clinical incidents.

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