Intramural Hematoma During Percutaneous Coronary Intervention: Recognition, Case-Based Insights, and Contemporary Management Strategies

Intramural hematoma (IMH) is an infrequent but clinically significant complication of percutaneous coronary intervention (PCI), characterized by blood accumulation within the medial layer, causing true lumen compression and impaired coronary flow. Often under-recognized on angiography, the use of intravascular imaging has enhanced diagnostic accuracy and facilitated timely management. This review outlines the pathophysiology and mechanisms of iatrogenic IMH during PCI, clinical presentations, and contemporary strategies for detection and treatment. Illustrative case examples highlight practical considerations. We discuss the roles of intravascular ultrasound (IVUS), optical coherence tomography (OCT), and near-infrared imaging in diagnosis; summarize interventional approaches including stenting, cutting/scoring balloons, and drug-coated balloons; and propose a pragmatic clinical management algorithm. This reinforces that early identification of PCI-related IMH coupled with imaging-directed therapy significantly improves procedural accuracy and correlates with more favorable long-term vascular outcomes.