A Case of an Obstructive Intramural Haematoma during Percutaneous Coronary Intervention Successfully Treated with Intima Microfenestrations Utilising a Cutting Balloon Inflation Technique

Figure 1. (a) Long segment of moderate to severe stenosis in the LAD. Arrows indicate the target segments for deployment of the stents. (b) Intima flap, following lesion predilatation (arrows).

Figure 2. (a) Significant luminal stenosis at the level of two small diagonal branches (arrows) after deployment of the stents and postdilatation of the overlapping segment with the 3.5 mm stent balloon at 16 atmospheres. Stenosis did not resolve after intracoronary administration of two consecutive 300 mcg bolus doses of nitrates. (b) Further overlapping stenting resulted in propagation of the haematoma and significant distal luminal stenosis after the level of the two small diagonal branches (arrows).

Figure 3. (a) Inflation of a 2.5 mm cutting balloon at nominal pressure at the transition of the stent struts to the adjacent unstented reference segment (arrows). (b) Restoration of normal TIMI 3 flow after inflation of cutting balloon at nominal pressure (arrows).

Figure 4. (a) Intramural haematoma (green arrow) can cause luminal obstruction, with significant flow disturbances resulting in significant ischaemia and ensuing myocardial infarction. (b) After single cutting balloon inflation at nominal pressure, the balloon blades generate several microfenestrations on the intima surface. The result is the creation of various blood exit points (blue arrows) that relieve the internal haematoma pressure towards the lumen of the vessel and restore normal blood flow.