The International Journal of Cardiovascular Imaging | 2019
Intramural hematoma squeeze causing carina shift during stent deployment. A preventable complication of coronary artery dissection treatment?
Abstract
68-years old woman with a clinical history of arterial hypertension and dyslipidemia even affected by moderate renal impairment (eGFR 40 ml/min). Since two months she complained dyspnoea due to physical effort, since three days before she complained also chest pain at rest. EKG and cardiac enzymes didn’t show any sign of acute ischemia. She was admitted at our catheterization laboratory for coronary angiography. The right coronary artery was patent without significant disease. Mild stenosis at left anterior descending (LAD) at the level of the first bifurcation with 2nd diagonal (Fig. 1a). To better investigate that lesion we performed OCT on the LAD and 2nd Diag. The lesion shows up as a sickleshaped and dark image between media and adventitia; at the intima wall an endothelial discontinuation can be appreciated (Fig. 1b). That image could be referred to an intramural hematoma. Because of the severity of the obstruction (MLA 3.3 cm2) we decided to proceed to PCI. We performed a pre-dilation with a semi-compliant balloon, followed by a 3.5 × 18 mm DES implantation. After DES implantation we observed a side branch occlusion (Fig. 1c), probably due to a hematoma “squeeze”. Stent implantation, without adequate lesion preparation, may have been propagate the hematoma toward the side branch, determining it’s suffering. We wired the side branch and we proceeded to predilate end than, a kissing balloon was performed (Fig. 1d). Then, we performed Intravascular ultrasound (IVUS) in order to minimize contrast media injections (renal impairment). IVUS showed the hematoma against the arterial wall, crushed by the stent (Fig. 1e). The final angiographic result was acceptable (Fig. 1f), the patient remained asymptomatic and she was discharged after 2 days. Spontaneous coronary intramural hematoma is a rarely cause of acute coronary syndrome; rupture of the vasa vasorum has been described as the most important mechanism. The limited resolution of IVUS may preclude exact delineation of the associated arterial deformation and underlying pathological processes. Optical coherence tomography (OCT) provides superior resolution on the order of 10–15 μm and may allow supplementary characterization of intramural abnormalities and associated entry and re-entry points [1]. Traditional treatment with balloon angioplasty or stenting may further propagate the compressive hematoma resulting in distal or proximal hematoma extension and subsequent luminal compression. The use of a cutting balloon has been proposed as a valid alternative to stent implantation by creating fenestrations to allow blood propagation into the true lumen and thereby, avoiding vessel compression [2].