Korean Circ J.  2010 Nov;40(11):596-600. 10.4070/kcj.2010.40.11.596.

A Case of Intra- and Extra-Mural Hematomas During Recanalization for Chronic Total Occlusion

• Kang SY
• Hur SH
• Choi HC
• Kim GS
• Cho YK
• Han CD
• Park HS
• Yoon HJ
• Kim H
• Nam CW
• Kim YN
• Kim KB

• KMID: 1826180
• DOI: http://doi.org/10.4070/kcj.2010.40.11.596

Abstract

An intramural hematoma is an accumulation of blood between the internal and external elastic membranes within the medial space, whereas an extramural hematoma is a dilution and/or dissemination of blood throughout the adventitia. Intra- and extra-hematomas are observed by intravascular ultrasound during percutaneous coronary intervention (PCI). The patient described herein presented with angina pectoris. Her coronary angiogram showed diffuse narrowing of the mid-left anterior descending artery and total occlusion of the distal right coronary artery (RCA). Intra- and extra-mural hematomas developed during PCI of the RCA; however, the lesions were covered successfully using long drug-eluting stents.

Keyword

Hematoma; Ultrasonography, interventional

MeSH Terms

Adventitia
Angina Pectoris
Arteries
Coronary Vessels
Drug-Eluting Stents
Hematoma
Humans
Membranes
Percutaneous Coronary Intervention
Ultrasonography, Interventional

Figure

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  Fig. 1 Diagnostic coronary angiogram revealed total occlusion of the distal RCA (A) and collateral flow from the left coronary artery system to the distal RCA (B). RCA: right coronary artery.

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  Fig. 2 After advancement of a Conquest Pro guidewire (Asahi, Seto, Japan) using a parallel guidewire technique to the RCA, a coronary angiogram showed that the tip of the guidewire was placed outside of the vessel (arrowhead; upper left). After several attempts to cross the CTO lesions, a Conquest Pro guidewire was succeeded to enter into the true lumen of the PL branch (upper right). The lower panel shows cross-sectional images, as well as a longitudinal image of the IVUS from the PL branch to the distal RCA. A and B: at the proximal reference (in the distal RCA) of the CTO, an intraluminal thrombus (★) and intramural hematoma (arrowheads) located in the normal arc of the arterial wall were identified. C: at the proximal end of the CTO, there were intramural hematomas (arrowheads) included with the accumulation of blood and contrast media at the suspected entry site (*). D, E and F: at the middle of the CTO, an extramural hematoma represented as an echo-dim pattern throughout an echogenic adventitia (arrows) and the suspected entry site was detected (*). G: at the distal end of the CTO (in the distal RCA bifurcation), an extramural hematoma was identified (arrows). H: at the proximal PL branch, an intimal dissection to the media from 3 to 6 o'clock was noted. I: at the distal reference in the PL branch. RCA: right coronary artery, CTO: chronic total occlusion, PL: posterolateral.

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  Fig. 3 Final coronary angiogram demonstrated no residual lumen narrowing with thrombolysis in myocardial infarction 3 flow. Post-stenting intravascular ultrasound images revealed well-opposed stent struts to the vessel wall (A-D) and a 4.66 mm2 minimal stent area (C).

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