Coronary artery intramural hematoma, a rare complication of percutaneous coronary intervention

Abstract

Coronary artery intramural hematoma is a rare complication of percutaneous coronary intervention which develops from intimal tear of coronary artery and propagates by blood accumulation along the medial surface of adjacent segment. Fifty-three-year-old male presented with nonexertional chest pain; he was referred after a positive stress test with+ moderate lateral wall ischemia. Coronary angiography showed 80% lesion in mid-left anterior descending artery (mLAD). Angiogram after angioplasty with 2.0 mm × 15 mm balloon and 3.0 mm × 15 mm drug-eluting-stent demonstrated a new stenotic lesion distal to stented mLAD segment. Subsequently, an overlapping 3.0 mm × 30 mm stent was placed with effective restoration of blood flow through LAD. During percutaneous coronary intervention (PCI), balloon predilatation can result in plaque fracture and stent deployment may cause intimal tear forming intramural hematoma which can lead to post-PCI myocardial infarction necessitating prompt detection by intravascular imaging with intravascular ultrasound and optical coherence tomography. Management is based on individual patient's characteristics and includes medical therapy, angiographic surveillance or repeat PCI.

Keywords: Angiogram; CIH, Coronary Intramural Hematoma; Coronary angiography; Coronary artery intramural hematoma; DES, Drug-eluting stent; ICU, Intensive care unit; IVUS, Intravascular Ultrasound; Iatrogenic myocardial infarction; LAD, left anterior descending artery; LVEF, left ventricular ejection fraction; OCT, Optical Coherence Tomography; PCI, Percutaneous Coronary Intervention; Percutaneous coronary intervention; Post-percutaneous coronary intervention myocardial infarction; mLAD, mid segment of left anterior descending artery.

Fig. 1

Diagnostic coronary angiograms. (A) Coronary angiogram showing 80% lesion in mid segment of Left Anterior Descending Artery (white arrow). (B) Angiogram showing luminal irregularities in right coronary artery.

Fig. 2

Balloon inflation and stent deployment. (A) Angioplasty was performed using 2.0 × 15 mm balloon. Stent can be seen in the left anterior descending artery (white arrow). (B). 2.0 mm × 15 mm balloon inflation and 3.0 × 15 mm drug eluting stent deployment (black arrow).

Fig. 3

Development of coronary intramural hematoma. (A) Angiogram showing newly appeared severely stenotic lesion (white arrow) distal to the freshly placed stent in left anterior descending artery. B. This sequence shows progression of the lesion known as coronary intramural hematoma (black arrow).

Fig. 4

New balloon insertion and failure to restore blood flow. (A) 2.50 mm × 30 mm balloon was inserted over the same wire and the lesion was ballooned (white arrow). (B) Subsequent angiogram after repeat balloon inflation did not show any improvement in the flow (black arrow).

Fig. 5

Repeat angioplasty and effective restoration of blood flow. (A) The entire new lesion was stented using 3.0 × 30 mm stent (white arrow). (B) Angiogram illustrates the successful placement of 3.0 × 30 mm DES and effective restoration of the coronary blood flow through LAD (black arrow).