Novel use of cutting balloon to manage compressive subintimal hematoma during left main stenting in a patient with spontaneous coronary artery dissection

Figures

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  Figure 1. Initial cardiac catheterization and intravascular ultrasound. (A) Caudal view of the left main coronary artery with diffuse loss of vessel diameter (arrow). (B) Left Main intravascular ultrasound exhibiting intramural hematoma (star) with luminal narrowing (dotted line). The solid line represents the adventitia. No obvious dissection flap was identified.

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  Figure 2. Repeat intravascular ultrasound of the left main coronary artery. The inner region (solid line) denotes the left main lumen. The outer region (dotted line) denotes the adventitia of the left main with evidence of intramural hematoma (star). There is further compromise of the left main lumen.

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  Figure 3. Repeat coronary angiogram. (A) Caudal view of the left coronary tree with angioplasty wires observed down the left anterior descending (star) and circumflex–obtuse marginal arteries (square). Extension of the hematoma is evidenced in the circumflex (arrow). (B) Positioning of two stents (SKS technique) into the left main‐left anterior descending and left main‐circumflex arteries prior to inflation. (C) Simultaneous inflation of both stents with “double‐barreling” in the left main. (D) Caudal angiogram revealing loss of the left circumflex–obtuse marginal circulation after stent deployment (white arrows). Also evidenced in this view is a dissection in the left main (black arrows).

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  Figure 4. Cutting balloon for management of propagated subintimal hematoma. (A) Angiogram of inflation of the cutting balloon in the left circumflex. (B) Caudal angiogram revealing restored flow down the left circumflex and obtuse marginal vessels with evidence of a dissection in both vessels (arrows).