Compressive Coronary Hematoma Treated With Stenting

Figures

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  Figure 1. Acute Presentation, Intracoronary Imaging, Primary Percutaneous Coronary Intervention, and 1-Month Angiographic and OCT Follow-Up (A) Electrocardiogram showing >12-mm ST-segment elevation in leads V2 to V4 with reciprocal changes. (B) Coronary angiography demonstrating severe filiform narrowing from the mid to distal left anterior descending artery (LAD), consistent with compressive intramural hematoma (IMH). (C to E) Pre-percutaneous coronary intervention optical coherence tomography (OCT) revealing circumferential (360°) IMH (white asterisk) causing severe true lumen collapse (minimal lumen area [MLA] 0.6 to 0.7 mm2). The true lumen is indicated by a white arrow. (F) Final angiographic result after implantation of 3 drug-eluting stents (60 mm total length) restoring TIMI flow grade 3. (G to I) Immediate poststenting OCT showing limited incomplete stent apposition, predominantly in the mid stented segment, proximal (MLA 6.66 mm2, diameter 2.92 mm), mid (MLA 6.29 mm2, diameter 2.83 mm), and distal (MLA 6.31 mm2, diameter 2.83 mm) segments. (J) One-month coronary angiography showing a satisfactory result. (K) One-month OCT demonstrating proximal acquired stent malapposition…

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  Figure 2. 2-Month OCT-Guided Optimization and LAD Stent Assessment During the 2-Year Left Main Event (A) Repeat coronary angiography at 2 months showing preserved TIMI flow grade 3. (B to D) OCT images before optimization demonstrating persistent but reduced proximal stent malapposition, measuring approximately 600 μm in depth over an 8-mm segment, with near-complete endothelialization (MLA 6.0 mm2, diameter 2.76 mm). The yellow arrow in panel B indicates proximal stent malapposition. (E to H) OCT-guided postdilation using a 4.0 × 12 mm EUPHORA balloon (Medtronic), resulting in optimal stent expansion and complete apposition (postdilation MLA 7.38 mm2, diameter 3.06 mm). The white asterisks in panels D and H indicate residual intramural hematoma. (I) Coronary angiography performed during hospitalization for left main SCAD at 2 years, demonstrating a dissection flap in the mid left main coronary artery (white arrow). The anatomical levels corresponding to the OCT cross-sections shown in (J to L) are marked by red arrows on (I). (J to L) OCT cross-sectional images of the previously implanted LAD stent obtained during the same hospitalization, showing preserved stent apposition and complete…

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  Figure 3. Left Main Spontaneous Coronary Artery Dissection at 2-Year Follow-Up and OCT-Guided Percutaneous Coronary Intervention (A) Coronary angiography at 2-year follow-up in right anterior oblique (RAO) caudal view showing a distal left main (LM) dissection with a double-lumen appearance involving the mid and distal LM and sparing the ostium. Injection was performed with a diagnostic JL 3.5 catheter. Red markers indicate the OCT levels shown in (B) to (D). (B to D) Corresponding OCT cross-sections at the ostial, mid, and distal LM levels showing a noncompressive intramural hematoma (asterisk) in the mid-to-distal LM, communicating with the true lumen. The white arrow indicates the intimal flap. MLA was 16.44 mm2 (diameter 4.57 mm) at the LM ostium, 15.43 mm2 (diameter 4.42 mm) at the mid-LM dissection site, and 12.98 mm2 (diameter 4.02 mm) in the distal left main affected by the intramural hematoma. (E) Final coronary angiography in RAO caudal view after implantation of a 4.5 × 12-mm stent in the LM, followed by postdilation with a 5.0-mm noncompliant balloon. Red markers indicate the OCT levels shown in F to H. (F to H) Post-percutaneous coronary intervention OCT cross-sections at the…

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  Figure 4. Computed Tomography Imaging of Systemic Arteriopathy (A) Volume-rendered reconstruction of the supra-aortic trunks showing tortuous extracranial internal carotid arteries with fusiform vascular ectasia and aneurysmal dilatations. (B) Volume-rendered reconstruction of both renal arteries showing irregularities of the mid segments with a characteristic “string-of-beads” appearance, consistent with fibromuscular dysplasia. (C) Multiplanar reconstruction (MPR) of the right internal carotid artery along the vessel axis showing marked tortuosity with fusiform ectasia and aneurysmal dilatations. (D) MPR maximum intensity projection reconstruction of the left renal artery along the vessel axis. (E) Curvilinear reconstruction of the right internal carotid artery. (F) MPR of the left internal carotid artery along the vessel axis. (G) Volume-rendered coronary reconstruction showing focal aneurysmal ectasia of the distal left main coronary artery (red arrow). (H) Curvilinear reconstruction of the right renal artery. The white arrows in panels A, C, and E indicate fusiform ectasia and aneurysmal dilatations of the carotid arteries.