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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 - Korean Circ J (2010)

Bottom Line: 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.

View Article: PubMed Central - PubMed

Affiliation: Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Medical Center, Daegu, Korea.

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.

No MeSH data available.


Related in: MedlinePlus

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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Figure 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.

Mentions: A 51-year-old woman was admitted with effort-induced chest pain. She had hypertension, diabetes, and hypercholesterolemia for 7 years. The physical examination and laboratory findings showed no abnormalities. A baseline electrocardiogram showed left ventricular hypertrophy by criteria and inverted T waves in the inferior leads and leads V4-V6. Gated myocardial scintigraphy demonstrated reversible perfusion defects in the anterior and inferior myocardial walls. An echocardiogram showed no regional wall motion abnormalities with preservation of the left ventricular ejection fraction. A 64 multi-slice computerized tomography showed significant stenosis in the mid-portion of the left anterior descending artery (LAD) and total occlusion in the distal portion of the right coronary artery (RCA). Similarly, a diagnostic coronary angiogram revealed diffuse narrowing of the mid-LAD (70%) and total occlusion of the distal RCA. There was grade 2 collateral flow from the LAD to the RCA via the septal branch (Fig. 1). The patient was initially scheduled to undergo PCI for recanalization of the RCA. The right coronary ostium was engaged with a 7-Fr Amplatz 4.0 guiding catheter and the left coronary ostium was cannulated with a 5-Fr Judkin catheter for the contralateral angiogram. With the support of a 1.5-mm over-the-wire balloon system (Boston Scientific, Natick, MA, USA), a PT ll (Boston Scientific) 0.014-inch guidewire was advanced. After failing the first guidewire passage, a Miracle 3 g, 6 g, and 12 g guidewires (Asahi, Seto, Japan) were sequentially attempted, but could not be passed into the distal true lumen. Therefore, a parallel wire technique using Miracle 12 g and Conquest Pro guidewires (Asahi) was attempted. By this parallel wire technique, a Conquest Pro guidewire was advanced to the totally occluded lesion. Following the angiogram, however, the tip of the Conqest Pro guidewire was shown to be placed outside of the vessel beyond the distal RCA bifurcation without extravasation of contrast media (Fig. 2). After repeated attempts to manipulate the guidewire, the Conquest Pro guidewire successfully entered the true lumen of the posterolateral (PL) branch and pre-dilatation with a Voyager balloon (2.5×20 mm; Abbott, Santa Clara, CA, USA) was performed. At this point, IVUS (Atlantis SR Pro 40 MHz; Boston Scientific) was performed to obtain vessel information as well as identification of PCI complications. The qualitative IVUS finding showed the following: 1) a hypo-echogenic, inhomogeneous, lobulated mass within the lumen in the distal RCA, suggesting an intraluminal thrombi (Fig. 2A and B), 2) a crescent-shaped, hypo-echogenic, accumulation of contrast media with displacement of the IEM into the lumen in the distal RCA, suggesting an intramural hematoma (Fig. 2B and C), 3) an eccentric inhomogeneous echogenecity, consistent with accumulated blood, in the proximal portion of the PL branch to the distal bifurcation site, and a probable communication site between the lumen and adventitia, suggesting an extramural hematoma (Fig. 2D-G), and 4) an intimal dissection to the media from 3 to 6 o'clock in the mid-portion of the PL branch (Fig. 2H). A quantitative IVUS measurement showed that a total lesion length from the PL branch to the mid-RCA was 50 mm and the distal reference diameter was 2.8 mm. For entire coverage of the occluded lesion, as well as intra- and extra-mural hematomas, 2 Taxus stents (3.0×28 mm and 2.75×28 mm; Boston Scientific) were implanted with an overlapping technique. The final coronary angiogram demonstrated no residual lumen narrowing with thrombolysis in myocardial infarction 3 flow (Fig. 3). A post-stenting IVUS revealed well-opposed stent struts to the vessel wall and a 4.66 mm2 minimal stent area (MSA) (Fig. 3C). Because the MSA was located at the distal bifurcation site with co-existing intra- and extra-mural hematomas and there was a risk of coronary rupture, no further intervention, such as adjunctive balloon dilatation, was performed. The next day, 2 additional Taxus stents (3.0×28 mm and 2.75×28 mm) were deployed with an overlapping technique for the mid-LAD lesion.


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 - Korean Circ J (2010)

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.
© Copyright Policy - open-access
Related In: Results  -  Collection

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Show All Figures
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Figure 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.
Mentions: A 51-year-old woman was admitted with effort-induced chest pain. She had hypertension, diabetes, and hypercholesterolemia for 7 years. The physical examination and laboratory findings showed no abnormalities. A baseline electrocardiogram showed left ventricular hypertrophy by criteria and inverted T waves in the inferior leads and leads V4-V6. Gated myocardial scintigraphy demonstrated reversible perfusion defects in the anterior and inferior myocardial walls. An echocardiogram showed no regional wall motion abnormalities with preservation of the left ventricular ejection fraction. A 64 multi-slice computerized tomography showed significant stenosis in the mid-portion of the left anterior descending artery (LAD) and total occlusion in the distal portion of the right coronary artery (RCA). Similarly, a diagnostic coronary angiogram revealed diffuse narrowing of the mid-LAD (70%) and total occlusion of the distal RCA. There was grade 2 collateral flow from the LAD to the RCA via the septal branch (Fig. 1). The patient was initially scheduled to undergo PCI for recanalization of the RCA. The right coronary ostium was engaged with a 7-Fr Amplatz 4.0 guiding catheter and the left coronary ostium was cannulated with a 5-Fr Judkin catheter for the contralateral angiogram. With the support of a 1.5-mm over-the-wire balloon system (Boston Scientific, Natick, MA, USA), a PT ll (Boston Scientific) 0.014-inch guidewire was advanced. After failing the first guidewire passage, a Miracle 3 g, 6 g, and 12 g guidewires (Asahi, Seto, Japan) were sequentially attempted, but could not be passed into the distal true lumen. Therefore, a parallel wire technique using Miracle 12 g and Conquest Pro guidewires (Asahi) was attempted. By this parallel wire technique, a Conquest Pro guidewire was advanced to the totally occluded lesion. Following the angiogram, however, the tip of the Conqest Pro guidewire was shown to be placed outside of the vessel beyond the distal RCA bifurcation without extravasation of contrast media (Fig. 2). After repeated attempts to manipulate the guidewire, the Conquest Pro guidewire successfully entered the true lumen of the posterolateral (PL) branch and pre-dilatation with a Voyager balloon (2.5×20 mm; Abbott, Santa Clara, CA, USA) was performed. At this point, IVUS (Atlantis SR Pro 40 MHz; Boston Scientific) was performed to obtain vessel information as well as identification of PCI complications. The qualitative IVUS finding showed the following: 1) a hypo-echogenic, inhomogeneous, lobulated mass within the lumen in the distal RCA, suggesting an intraluminal thrombi (Fig. 2A and B), 2) a crescent-shaped, hypo-echogenic, accumulation of contrast media with displacement of the IEM into the lumen in the distal RCA, suggesting an intramural hematoma (Fig. 2B and C), 3) an eccentric inhomogeneous echogenecity, consistent with accumulated blood, in the proximal portion of the PL branch to the distal bifurcation site, and a probable communication site between the lumen and adventitia, suggesting an extramural hematoma (Fig. 2D-G), and 4) an intimal dissection to the media from 3 to 6 o'clock in the mid-portion of the PL branch (Fig. 2H). A quantitative IVUS measurement showed that a total lesion length from the PL branch to the mid-RCA was 50 mm and the distal reference diameter was 2.8 mm. For entire coverage of the occluded lesion, as well as intra- and extra-mural hematomas, 2 Taxus stents (3.0×28 mm and 2.75×28 mm; Boston Scientific) were implanted with an overlapping technique. The final coronary angiogram demonstrated no residual lumen narrowing with thrombolysis in myocardial infarction 3 flow (Fig. 3). A post-stenting IVUS revealed well-opposed stent struts to the vessel wall and a 4.66 mm2 minimal stent area (MSA) (Fig. 3C). Because the MSA was located at the distal bifurcation site with co-existing intra- and extra-mural hematomas and there was a risk of coronary rupture, no further intervention, such as adjunctive balloon dilatation, was performed. The next day, 2 additional Taxus stents (3.0×28 mm and 2.75×28 mm) were deployed with an overlapping technique for the mid-LAD lesion.

Bottom Line: 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.

View Article: PubMed Central - PubMed

Affiliation: Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Medical Center, Daegu, Korea.

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.

No MeSH data available.


Related in: MedlinePlus