Coronary Intramural Hematoma with Dissection after Balloon Dilatation ; Treated With a Bare Metal Stent

- Operator : Seong-Wook Park

Coronary Intramural Hematoma with Dissection after Balloon Dilatation ; Treated With a Bare Metal Stent

- Operator: Seong-Wook Park, MD, PhD, Korea

Clinical history

Forty-three year old man presented with an effort chest pain for 4 months. He had a smoking as coronary risk factors. His baseline ECG showed T inversion in precordial leads. Thallium SPECT showed partially reversible large sized severely decreased perfusion defect in LAD territories and reversible medium sized decreased mildly perfusion defect in inferior wall. Baseline echocardiogram showed regional wall motion abnormalities in apical, inferior, and middle septal wall with 55% of LV ejection fraction.

Baseline coronary angiography

The initial left coronary angiogram showed diffuse significant narrowing of the middle LAD and subtotal occlusion of distal LCX (Figure 1, Figure 2). The right coronary artery was normal.

Procedure

We obtained right common femoral artery access and inserted a 7 F femoral sheath through right femoral artery. The left coronary was engaged with a 7 F AL2 guiding catheter. After predilation in LAD (Figure 3), the proximal LAD was more narrowed and dye staining of arterial wall was noted (Figure 4, Figure 5). So, IVUS was done to evaluate the new proximal LAD lesion. IVUS image showed the dissection and cresenteric shaped intramural hematoma with compression of coronary lumen at 4-9 O’clock, extending to the ostial LAD (Figure 6). We intended to treat this lesion with stenting and the middle LAD lesion was stented first with a 3.0x25mm NIR-Elute stent (Figure 7). Then the proximal dissection and intramural hematoma was treated with a 3.5x15mm NIR-Elute stent (Figure 8). Following coronary angiogram showed good result without visible dissection (Figure 9, Figure 10, Figure 11). Although following IVUS image showed minimal remnant intramural hematoma in the distal left main coronary artery, the lumen was not compromised (Figure 12). Therefore we finished the procedure. The LCX lesion was not treated because the reference vessel was small.