Spatial Mismatch Between Angiographic Obstruction and Plaque Destabilization in Acute Coronary Syndromes: A Conceptual Narrative Review.

The identification of the "culprit lesion" in acute coronary syndromes (ACS) traditionally relies on coronary angiography, assuming that the most severe stenosis, abrupt occlusion, or largest filling defect marks the site of plaque destabilization. However, this two-dimensional luminographic view cannot directly characterize plaque morphology or capture the spatial and temporal evolution of coronary thrombosis. We propose Spatial Culprit Mismatch (SCM) as a hypothesis-generating framework describing selected cases in which the dominant angiographic obstruction is spatially separated from a more proximal plaque-disruption phenotype identified by intracoronary imaging, especially with the use of optical coherence tomography (OCT). Potential mechanisms include longitudinal thrombus propagation, distal embolization, partial lysis, and repeated thrombosis and healing. SCM should not be inferred from angiography or OCT morphology alone; alternative embolic sources, multiple unstable plaques, and imaging limitations must be considered. Prospective studies are required to determine its prevalence, impact, and whether any SCM-directed treatment improves outcomes.