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

Intramural hematoma extending from a dissection within an implanted stent: a case report treated with fenestration using a cutting balloon

Background

Dissection after balloon dilation or stent implantation is a common complication of percutaneous coronary intervention. In general, coronary stent implantation for coronary artery dissection is safe when the dissection is completely covered by the stent, particularly when dissection occurs during pre-dilation. However, here, we report a case of severe restenosis caused by a pre-dilation hematoma that extended after stent implantation.

Case summary

A 76-year-old man was diagnosed with angina on exertion and underwent percutaneous coronary intervention in the right coronary artery. After pre-dilation with a cutting balloon, non-flow-limiting dissection occurred. An everolimus-eluting stent was implanted, completely sealing the dissection, and intravascular ultrasound revealed adequate stent expansion without stent edge dissection. Two weeks after the procedure, confirmatory coronary angiography revealed severe restenosis extending from the distal stent edge to the distal right coronary artery. Intravascular ultrasound revealed a hematoma extending from the middle of the stent to the distal segment.

Discussion

The patient had been on steroids for a long time. The cutting balloon used for pre-dilation may have created a deep dissection reaching the tunica media, already rendered vulnerable by steroids, potentially leading to injury to the vasa vasorum. The intramural hematoma from the bleeding vasa vasorum might have been the underlying cause of this phenomenon, as evidenced by its increase in size despite the entry of the dissection being completely sealed. Cardiologists should be aware of this possibility.

Cutting balloon for femoral arterial and venus obstructions due to suture-based closure devices: Case series

Suture-based vascular closure devices have been shown to be effective in hemostasis for procedures with vascular access. However, iatrogenic vascular occlusion may occur. The cutting balloon (CB) is a noncompliant balloon wrapped with 3-4 microsurgical blades that are intended to modify vascular lesions, but it may also be utilized to cut and release endovascular sutures. We report two cases in which the CB was employed as a bailout strategy to alleviate suture-related vascular occlusion after transcatheter aortic valve replacement. The CB can be effectively utilized to resolve suture-related vascular occlusion.

Compressive Coronary Intramural Hematoma: A Case Report

Despite the advancement of various devices and techniques, percutaneous coronary intervention (PCI) of chronic total occlusion (CTO) lesion remains one of the major challenges in interventional cardiology fields. It is also associated with higher complications than non-CTO-PCI due to procedural complexity. We presented a case of iatrogenic compressive coronary intramural hematoma (IMH) as CTO-PCI complications, which was judiciously detected and successfully managed with a cutting balloon.