Background: Spontaneous coronary artery dissection (SCAD) is one of the causes of acute coronary syndrome, myocardial infarction (MI) and sudden death. Although the gold standard for diagnosis is invasive coronary angiography, Coronary Computed Tomography Angiography (CCTA) is a new useful tool for the diagnosis and follow-up (FU). Treatment could involve a conservative or an invasive approach with percutaneous coronary intervention (PCI) or coronary artery bypass grafting. AIMS: 1) analyze the clinical and CCTA features at baseline of patients with SCAD; 2) evaluate the clinical and anatomic patients outcome with conservative or invasive treatment; 3) evaluate in patients treated with the conservative approach the clinical and anatomic features of those dismissed with single (SAPT) or double (DAPT) antiplatelet therapy. Methods: Clinical and anatomic data of 57 patients with SCAD, followed up with CCTA enrolled retrospectively between 2010 ad 2022, were collected at baseline and at the FU. The clinical endpoints evaluated were: all causes mortality, hospitalization for cardiovascular cause, SCAD or PCI ex-novo and MI. The anatomic endpoints were: patency of coronary artery and/or stents and length dissection changing from baseline. Results: 46 (80,7%) patients underwent a conservative treatment and 11 (19,3%) under PCI. Patients treated with PCI were more smokers (45,5% vs 15,2%; p=0,042), had peripherical arteriopathy (18,2% vs 0%; p=0,034), higher troponin peak (40425,8 vs 13436; p=0,011) and lower ejection fraction (51,4±11,0 vs 57,1±7,6; p=0,050). Moreover the PCI population had a significant involvement of more than one coronary artery (72,7% vs 6,5%; p<0,001), of the proximal tracts of the coronary arteries (22,8% vs 13 %; p=0,001) and of the truncus communis (45,4% vs 0%; p<0,001). At the FU, there were no statistical differences for clinical and anatomic endpoints between the two groups (p>0,05). Among patients treated with conservative therapy, there was a more significant recurrence of SCAD in those treated with DAPT than in those treated with SAPT (33,3% vs 5,9%; p=0,033). Conclusions: patients with SCAD managed with PCI have more cardiovascular risk factors, a major myocardial infarction extension and a more complex coronary arteries involvement; conservative management is comparable to the PCI treatment for the clinical and anatomic endpoints evaluated. DAPT at discharge is associated with a higher rate of SCAD recurrence at FU.