- Intramural hematoma (IMH) appears on imaging as a crescent-shaped accumulation of blood within the vessel wall. IVUS can clearly identify IMH but OCT may worsen dissections. - The management of IMH is not well-defined but approaches include cutting balloons, stenting spiral dissections under IVUS guidance, and initially conservative management for stabilized spontaneous coronary artery dissection patients. - Case examples demonstrate identifying IMH by IVUS and treating with cutting balloons or stenting under IVUS guidance for optimal results. IMH appears similar to dissection and requires precision treatment to prevent complications.

1. Coronary Intramural Hematomas:
Image Characteristics and Management
Po-Ming Ku, MD. 顧博明醫師
Cardiovascular Center, Chi-Mei Hospital, Liuoying.
柳營奇美醫院 心血管中心
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0
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2. Intramural hematoma (IMH)
• 2003ACC Task Force defined as an
accumulation of blood within the
medial space displacing the internal
elastic membrane inward and the
external elastic membrane outward,
with or without identifiable entry and
exit points.
• Intramural hematomas were typically
crescent-shaped, with straightening of
the internal elastic membrane.
IVUS

3. 2011 Tainan, Taiwan

4. Cardiovasc Diagn Ther.
2015 Aug; 5(4): 323-9.

5. Imaging IMH
• IVUS:
– Dissection: 可用
– No flow: 看得到
– Localization: 可以
– IMH影像：較清晰
– stent apposition:不清晰
• OCT:
– Dissection: 可能惡化夾層
– No flow: 看不到
– Localization:不可以
– IMH影像：不清晰
– stent apposition:較清晰

6. IMH (2)
• Maehara A. et al reported 905 pts with 1025 consecutive PCI by
IVUS evaluation. Circulation. 2002;105:2037-42.
• The incidence of IMH per artery was 6.7%.
• 36% involved the proximal reference artery, 46% distal .
• The entry site was identified in 86% of IMH.
• 60% of the IMH: the angiogram had the appearance of a dissection;
• 11% of the IMH, it appeared to be a new stenosis by angio.
• 29% of the IMH, no significant abnormality was detected by angio.

7. IMH (3)
• The proper management of IMH has not been well-defined.
南都伸介 編 PCI テクニック 2008ed
Page 109.
4.0x4.3mm

8. 78M, typical anina for 2 mons
Thallium scan: myocardial ischemia on lateral wall.
2011 Tainan, Taiwan

9. DK mini-crush technique
(Taxus Liberte 2.75/16mm stent, Sprinter 4.0/10mm BC)

10. After 1st crush
IVUS
initial

11. IMH documented by IVUS  cutting
3.5/10mm cutting
2011 Tainan, Taiwan

12. After cutting
2011 Tainan, Taiwan

13. After cuttingBefore cutting
2011
Tainan,
Taiwan

14. IMH ≈ dissection

15. Tx for dissections: (IMH ≈ dissection)
(1) stent edge dissection
(2) spiral dissection
(3) spontaneous coronary artery dissection (SCAD)

16. The CLI-OPCI study - Angiography alone versus
angiography plus OCT to guide decision-making during
PCI: imaging and clinical results
stent edge dissection

20. How to rescue by stenting
spiral dissection
spiral dissection

22. Patient data:
• 52M, typical angina for 7 mons.
• H/T, Dyslipidemia, smoking. DM nephropathy (Cr = 2.2mg/dl)
• 3-V CAD, failed PCI for RCA-CTO 2 weeks ago at another hospital.
2009 Tainan, Taiwan

23. 2009 Tainan, Taiwan

24. No IVUS, 1st stenting
2009 Tainan, Taiwan

25. 2nd stenting
2009 Tainan, Taiwan

26. 3rd stenting
2009 Tainan, Taiwan

27. 2009 Tainan, Taiwan

28. 。Uneventful, no more angina.
。 F/U CAG 3 months later.
2009 Tainan, Taiwan

29. 72F, stable angina, CCS Fc 2-3,
DM, dyslipidemia, 3-V-D,
Referred after failed PCI to RCA-CTO 1 month ago.
SYNTAX score: 31
2009 Tainan, Taiwan

30. After 1.25mm POBA through side branch technique
2009 Tainan, Taiwan

31. Rewiring with Fielder FC GW through
Crusade microcatheter
2009 Tainan, Taiwan

32. IVUS 2009 Tainan, Taiwan

33. RCA-P RCA-D
2.5x3.0; CSA 5.9
EEM: 2.5x2.7mm

34. RCA-P
88mm
Strategy: Full metal jacket stenting
2.5x3.0; CSA 5.9
EEM: 2.5x2.7mm

35. Full metal jacket
3rd DES 3.0/32mm, 16 atm Final angiography
2009 Tainan, Taiwan

36. RCA-DRCA-P

37. 12 months later
2010 Tainan, Taiwan

39. Noh HJ, et al.

40. Noh HJ, et al.

41. IMH
IMH
IMH
After
cutting

42. L’t, transradial, JR4 catheter
2010 Tainan, Taiwan
66M, typical angina with Tl scan: inferior wall myocardial ischemia.
DM, HCVD, Dyslipidemia.

43. Mild angina, p’t refused CABG
2010 Tainan, Taiwan

44. Next day (No angina, cardial enz: np)
2010 Tainan, Taiwan

45. Transfemoral, 6F, SCR 4 GC,
Fielder FC GW in 1.5mm O-T-W balloon catheter
2010 Tainan, Taiwan

46. 1.5 mm POBA
2010
Tainan
Taiwan

47. No IVUS, contrast injection by O-T-W BC
2010 Tainan, Taiwan

48. 2.5/20 mm POBA (3-8 atm)
2010 Tainan, Taiwan

49. Tsunami 2.5/24 mm stenting
2010 Tainan, Taiwan

50. Final
2010 Tainan, Taiwan

51. 46F, angina for 16 hrs, Tn-I 16.8ng/dl
no CAD risk factor
2013 Tainan, Taiwan

52. POBA
2013 Tainan, Taiwan

53. 2.5/32 mm BMS, 12 atm
2013 Tainan, Taiwan

54. after stenting Initial
2013 Tainan, Taiwan

55. Spontaneous coronary artery dissection
2013
Tainan
Taiwan

56. an initial conservative approach “watchful waiting strategy”
for stabilized patients with SCAD

57. Take Home Messages
• IMH: cutting balloon: artery = 1.2 :1
• Stent edge dissection: 0.2mm, 0.6mm, 0.3mm
• IVUS-guided rescue spiral dissections.
• SCAD: watchful waiting strategy for stabilized patients
Just do IVUS

58. ☺ Thanks for your attention ☺

59. 64M, unstable angina for 10 days SYNTAX score: 12
crescendo angina on exertion
Tainan, Taiwan. 2015

60. OCT without pre-dilatation
Tainan, Taiwan. 2015

61. 1.5/20 mm-POBA, then OCT
Tainan, Taiwan. 2015

62. OCT
Tainan, Taiwan. 2015

63. NC Quantum 4.5/20mm, 12 atm
Tainan, Taiwan. 2015

64. OCT
Tainan, Taiwan. 2015

65. IVUS
Tainan, Taiwan. 2015

66. Omega 4.5/24mm, 12 atm
Tainan, Taiwan. 2015

67. IVUS
Tainan, Taiwan. 2015

68. OCT
Tainan, Taiwan. 2015

69. NC Quantum 5.0/12mm, 12 atm
Tainan, Taiwan. 2015

70. OCT and final angio
Tainan, Taiwan. 2015

71. Cardiovasc Diagn Ther. 2015 Aug; 5(4): 323-9.