Cutting balloon fenestration for wire-induced distal vessel dissection: a case report and clinical insights

Introduction and importance: Wire-induced coronary artery injury may result in significant vessel dissection, intramural hematoma (IMH), and loss of distal coronary flow. Urgent intervention may be required to restore coronary perfusion, although managing these cases can be challenging due to technical and procedural limitations. Case presentation: An 80-year-old male presented with an ST-elevation myocardial infarction and underwent left circumflex artery percutaneous coronary intervention complicated by wire-induced distal dissection, IMH, and VF. Balloon dilatation failed, but intravascular ultrasound (IVUS) guided balloon fenestrations restored the flow, followed by successful stenting. Clinical discussion: Wire-induced distal coronary dissections are rare but can lead to critical ischemia. IVUS plays a key role in confirming wire position, assessing the extent of hematoma, and guiding precise intervention. Although cutting balloon (CB) fenestration has primarily been described in spontaneous coronary artery dissection, this technique can serve as a valuable bailout strategy in iatrogenic dissections when conventional balloon dilatation fails. Controlled micro-incisions created by the CB enable hematoma drainage and flow restoration while minimizing further vessel trauma, even in small distal segments. Conclusion: Cutting balloon fenestration under IVUS guidance may represent a feasible bailout strategy for flow-limiting, wire-induced dissections complicated by IMH.