Extensive intramural hematoma as the cause of failed coronary angioplasty: diagnosis by intravascular ultrasound and treatment by stent implantation

Intramural hematoma burrowing behind a coronary stent: Optical coherence tomography findings

A 47-year-old patient underwent elective percutaneous coronary intervention for two separate lesions in left circumflex artery with a intervening normal segment. After completion of the procedure, there was abrupt vessel closure in the intervening normal segment. Intracoronary imaging using optical coherence tomography (OCT) demonstrated a large intramural hematoma (IMH) extending distally behind the stent. We describe the OCT findings of IMH using cross-sectional, longitudinal and stent-rendered images, and discuss its management.

Fenestration using a novel cutting balloon for acute vessel occlusion secondary to intramural hematoma following stent implantation

Intramural hematoma after percutaneous coronary angioplasty is associated with adverse events and requires immediate bail out; however, the optimal treatment approach has not yet been established. Herein, we describe a case of coronary occlusion due to an intramural hematoma following stent implantation in the mid left anterior descending (LAD) coronary artery. Intravascular ultrasound revealed a massive intramural hematoma from the distal edge of the stent to the distal segment of the LAD, and the true lumen was completely compressed. By performing fenestration with a Wolverine™ Cutting Balloon™ (Boston Scientific, Massachusetts, United States), we were able to bail out without additional stenting. In conclusion, a cutting balloon with improved crossability can be an effective management strategy for intramural hematoma.

A case of intra- and extra-mural hematomas during recanalization for chronic total occlusion

An intramural hematoma is an accumulation of blood between the internal and external elastic membranes within the medial space, whereas an extramural hematoma is a dilution and/or dissemination of blood throughout the adventitia. Intra- and extra-hematomas are observed by intravascular ultrasound during percutaneous coronary intervention (PCI). The patient described herein presented with angina pectoris. Her coronary angiogram showed diffuse narrowing of the mid-left anterior descending artery and total occlusion of the distal right coronary artery (RCA). Intra- and extra-mural hematomas developed during PCI of the RCA; however, the lesions were covered successfully using long drug-eluting stents.

Intravascular ultrasound-guided troubleshooting in a large hematoma treated with fenestration using a cutting balloon

Intramural hematoma formation is not a well-studied complication of percutaneous coronary intervention. We describe a patient with stable angina who developed an intramural hematoma during elective percutaneous coronary intervention (PCI) in the right coronary artery (RCA). Total occlusion with dense dye staining developed a long way from the distal RCA, near the posterior descending artery bifurcation site. The true lumen was compressed by the enlarged, tense, false lumen. The patient was successfully treating with intravascular ultrasound-guided fenestration using a cutting balloon, and a stent was implanted in the distal RCA.

A bleeding kiss: intramural haematoma secondary to balloon angioplasty

Background

Intramural coronary haematoma following percutaneous coronary intervention in the absence of coronary dissection is a rare phenomenon.

Case presentation

A 69 year old lady with previous prosthetic aortic valve replacement underwent percutaneous coronary intervention (PCI) from the left mainstem to the left anterior descending artery (LAD) and kissing balloon inflations to the LAD and circumflex (Cx) arteries. Although intravascular ultrasound examination (IVUS) of both the LAD and Cx showed both vessels to be widely patent at the end of the procedure, she developed ischaemic chest pain six hours later. Repeat coronary angiography revealed a significant stenosis in the proximal Cx vessel, which was confirmed on IVUS to be intramural haematoma.

Conclusion

In patients taking warfarin in addition to standard antiplatelet therapy, kissing balloon inflations should be carried out with caution.

Luminal narrowing due to intramural hematoma shift from left anterior descending coronary artery to left circumflex artery

This case report demonstrates subacute luminal narrowing 20 days after balloon angioplasty in the left anterior descending coronary artery due to an intramural hematoma. Stenting was performed and resulted in side-branch compromise caused by squeezing the hematoma from the left anterior descending coronary artery into the left circumflex artery. Another stent was deployed to treat the stenosis in the left circumflex artery.

Left atrial compression by a pericardial hematoma presenting as an obstructing intracavitary mass: a difficult differential diagnosis

IMPLICATIONS

The differential diagnosis of extracavitary, intramural and intracavitary disease may be difficult. An extrinsic compression of the left atrium by a dissecting pericardial hematoma was misdiagnosed as an intracavitary mass, by echocadiography and computer tomography. This case emphasizes the importance of patient history and clinical setting.

Extramural vessel wall hematoma causing a reduced vessel diameter after coronary stenting: diagnosis by intravascular ultrasound and treatment by stent implantation

An extramural vessel wall hematoma occurred immediately after implanting a coronary stent in an in-stent-restenosis of the intermedius branch. Angiography showed a significant luminal reduction distal to the intervention site. Intravascular ultrasound revealed an extramural echolucent zone compressing the vessel lumen. Stent implantation compressed the hematoma and allowed adequate myocardial perfusion. This demonstrates the value of intravascular ultrasound (IVUS) in cases of unusual angiographic results which can help to manage complications after coronary intervention.