Coronary artery Intramural hematoma - Case discussion Evidence review. Management.

1. Coronary Intramural hematoma
(IMH)

2. Definition
• Coronary Dissection
– Separation between any 2 coronary artery layers –
Intima/Media or Media/Adventitia – forming a
false lumen within the artery.

3. NHLBI classification for intimal tears
• Developed in the pre-stent era for the
classification of dissection types after balloon
angioplasty, but still relevant.
Coronary Artery angiographic changes after PTCA.
Manual of Operations NHBLI PTCA Registry 1985

4. NHLBI) classification for intimal tears
• Developed in the pre-stent era for the
classification of dissection types after balloon
angioplasty, but still relevant.
Coronary Artery angiographic changes after PTCA.
Manual of Operations NHBLI PTCA Registry 1985

5. PCR-EAPCI Textbook of PCI, 2013

6. Classification of dissection of
according to IVUS
• Intimal: Limited to the intima or atheroma, and not
extending to the media.
• Medial: Extending into the media.
• Adventitial: Extending through the EEM.
• Intramural hematoma: An accumulation of blood
within the medial space, displacing the internal elastic
membrane inward and EEM outward. Entry and/or exit
points may or may not be observed.
• Intra-stent: Separation of neointimal hyperplasia from
stent struts, usually seen only after treatment of in-
stent restenosis.
ACC Standards for acquisition, measurement and reporting of IVUS, 2001

7. Causes of intramural hematoma
• Post-PCI or stenting
• Peripartum state
• Coronary vasospasm
• Connective tissue disease; Vasculitis

11. • IVUS study of 905 patients with 1025
consecutive native coronary artery, non–in-
stent restenosis lesions undergoing PCI

13. • IVUS identified IMH in 6.7% PCIs
(72 Hematomas)
• Mechanism seemed to be a dissection into the
media where accumulation occurred because of
a lack of re-entry

14. IVUS findings
• 36% Proximal reference artery
• 18% Confined to the lesion
• 46% Distal reference artery
• Entry site from the lumen into the hematoma
was identified in 86%
• Re-entry site was identifiable in only 8%
• Axial extension of the hematoma was distal in
63% and proximal in 37%.

15. Angiographic Findings
• 60% hematomas Angiographic dissection
Type B in 24%
Type C in 52%
Type D in 24%
• 11% hematomas Angiographic new stenosis
• 29% hematomas No significant angiographic
abnormality

16. Management
• 51 hematoma sites Stented
• 10 hematoma sites Additional POBA
• 11 hematoma sites Not treated
• 1 patient GP2b3ai only

17. Management
• All stented arteries had no residual
dissection/hematoma
• All arteries in POBA group had residual
hematomas after additional balloon
angioplasty. However, the lumen area at the
hematoma site increased.
• Five POBA cases had a new re-entry site
created by additional balloon angioplasty –
visible dissection patched with stent

18. Clinical outcome
(Periprocedural)

19. OTHER CASE REPORTS

20. • 42/F
• Postmenopausal
• AWMI
• STK+
• Mid LAD PTCA+DES

24. • Patient hemodynamically stable/No chest pain
– referred to higher centre

25. • Repeat CAG

27. • MFU for 3
days
• Repeat CAG

28. • LM-LCX stent
shifted
hematoma
into LAD

29. • LM-LCX stent
shifted
hematoma
into LAD
• Culotte
stenting –
LM-LCX and
LM-LAD

31. • 51/M
• HTN/AOE/TMT+
• DVD - PTCA+DES to LAD, LCX

34. • Additional DES in LAD
• No residual dissection/hematoma

36. • 53/F
• Post-menopausal
• HTN
• NSTEMI/Killip 1
• Diagonal diseased
• MFU

39. • 4 months later
• NSTEMI/Killip 3

42. • Bifurcation stenting
in LAD-LCX
(V-stenting)

43. CONCLUSIONS
• Intramural hematoma is a not so uncommon
complication of PCI
• Rarely it maybe spontaneous
• May be clinically silent, cause Angina, ACS,
even SCD
• Results in adverse clinical outcomes

44. CONCLUSIONS
• No consensus regarding optimal management
• Management according to clinical
status/radiographic or IVUS severity
• IVUS helps in accurate diagnosis and
management
• Early recognition and management is key to
avoid catastrophe