Coronary intramural hematoma: Challenges in diagnosis and management

Abstract

Coronary intramural hematoma (CIH) after percutaneous coronary intervention (PCI) is a rare cause of acute coronary syndrome. As the diagnosis is really challenging, its incidence is really under estimated. The optimal management of post-PCI CIH has not been well defined. Conventional coronary angiography alone is often insufficient to identify a CIH. Intravascular ultrasound and optical coherence tomography (OCT) are helpful modalities for diagnosis and evaluation of its extension. We present a case of CIH after PCI, highlighting our experience in the diagnostic accuracy of OCT and our strategy in the management of this case.

An Uncommon Cause of ST-Segment Elevation Myocardial Infarction

“…IMCH is a subset of coronary dissection that occurs when blood accumulates in the media due to intimal tear or rupture of the vasa vasorum resulting in luminal narrowing that can lead to MI, arrhythmias, cardiogenic shock, and sudden cardiac death ( 2 , 3 , 4 ).…”

“…Spontaneous or trauma-related IMCH is a rare, under-recognized, and challenging diagnosis responsible for up to 1% to 4% of all MIs ( 2 ). It is more commonly seen as an iatrogenic complication in 6.7% of percutaneous coronary intervention (PCI) cases ( 3 ). Although scarcely reported, it has been described after motor vehicle accidents and with contact sports ( 1 ).…”

“…Having made an anatomic diagnosis of spontaneous or traumatic coronary artery dissection or IMCH, the operator must decide whether immediate revascularization is warranted. As opposed to atherothrombosis-related MI for which early revascularization is recommended, retrospective studies with spontaneous coronary artery dissection (SCAD) seem to favor revascularization only if high-risk features such as ongoing/recurrent ischemia, hemodynamic instability, TIMI flow grade 0 to 1, or sustained ventricular arrhythmias are present ( 2 , 3 ). PCI remains the preferred revascularization strategy over surgery except in cases of unprotected left main or proximal 2-vessel SCAD ( 1 , 6 ).…”

“…PCI remains the preferred revascularization strategy over surgery except in cases of unprotected left main or proximal 2-vessel SCAD ( 1 , 6 ). Nonetheless, PCI may be subject to worse outcomes in patients with IMCH/dissection if there is axial extension of the hematoma or iatrogenic dissection or inadvertent stenting of the false lumen ( 3 , 6 ). Accordingly, intracoronary imaging is mandatory to ensure intraluminal position and adequate coverage of the IMCH extension, with meticulous attention to stent positioning and sizing ( 2 ).…”

“…( 8 ) demonstrated angiographic resolution of SCAD in 29 of 30 (97%) patients after 1 month of conservative treatment with a 100% survival rate after a median follow-up of 4.5 years. Retrospective studies seem to favor an initial conservative approach as opposed to early revascularization in stable patients with SCAD without high-risk features, which may be extrapolated to those with traumatic IMCH-related MI because no large series informing of comparative treatment outcomes have been published ( 2 , 3 , 4 )…”