Failure of intravascular ultrasound to predict dissection after balloon angioplasty by using plaque characteristics

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.

Incidence, morphology, angiographic findings, and outcomes of intramural hematomas after percutaneous coronary interventions: an intravascular ultrasound study

BACKGROUND

Intramural hematomas during percutaneous coronary intervention (PCI) have not been well studied.

METHODS AND RESULTS

We used intravascular ultrasound to determine the incidence, morphology, and clinical features of post-PCI intramural hematomas. In 905 patients with 1025 consecutive native coronary artery, non-in-stent restenosis lesions undergoing PCI, 72 hematomas were detected in 69 arteries in 68 patients. The incidence of intramural hematomas per artery was 6.7% (69 of 1025); 36% (26 of 72) involved the proximal reference artery, 18% (13 of 72) were confined to the lesion, and 46% (33 of 72) involved the distal reference artery. The entry site from the lumen into the hematoma was identified in 86% of hematomas (62 of 72) and had the appearance of a dissection into the media. Conversely, a re-entry site was identifiable in only 8% (6 of 72). The axial extension of the hematoma was distal in 63% and proximal in 37%. In 60% of the hematomas (42 of 72) the angiogram had the appearance of a dissection; in 11% (8 of 72), it appeared to be a new stenosis; and in 29% (22 of 72), no significant abnormality was detected. Non-Q-wave myocardial infarctions occurred in 26% of patients (17 of 65). In 3 patients, the creatine kinase-MB was not measured during the hospital stay. Repeat revascularization occurred in 2 patients in-hospital, 2 additional patients at 1 month, and 8 additional patients at 1 year. There were 3 sudden deaths at 1 year.

CONCLUSIONS

Intravascular ultrasound identified intramural hematomas after 6.7% of PCIs. The mechanism appeared to be a dissection into the media where blood accumulated because of a lack of re-entry. A third of ultrasound-identified hematomas showed no angiographic abnormalities. There was a high rate of non-Q-wave myocardial infarction, need for repeat revascularization, and sudden death in patients with hematomas.