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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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

2011 Tainan, Taiwan

Cardiovasc Diagn Ther.

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

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

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.

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

78M, typical anina for 2 mons

Thallium scan: myocardial ischemia on lateral wall.

2011 Tainan, Taiwan

DK mini-crush technique

(Taxus Liberte 2.75/16mm stent, Sprinter 4.0/10mm BC)

After 1st crush

IVUS

initial

IMH documented by IVUS cutting

3.5/10mm cutting

2011 Tainan, Taiwan

After cutting

2011 Tainan, Taiwan

After cuttingBefore cutting

2011

Tainan,

Taiwan

IMH ≈ dissection

Tx for dissections: (IMH ≈ dissection)(1) stent edge dissection

(2) spiral dissection

(3) spontaneous coronary artery dissection (SCAD)

The CLI-OPCI study - Angiography alone versus

angiography plus OCT to guide decision-making during

PCI: imaging and clinical results

stent edge dissection

How to rescue by stenting

spiral dissection

spiral dissection

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

2009 Tainan, Taiwan

No IVUS, 1st stenting

2009 Tainan, Taiwan

2nd stenting

2009 Tainan, Taiwan

3rd stenting

2009 Tainan, Taiwan

2009 Tainan, Taiwan

。Uneventful, no more angina.

。 F/U CAG 3 months later.

2009 Tainan, Taiwan

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

After 1.25mm POBA through side branch technique

2009 Tainan, Taiwan

Rewiring with Fielder FC GW through

Crusade microcatheter

2009 Tainan, Taiwan

IVUS 2009 Tainan, Taiwan

RCA-P RCA-D

2.5x3.0; CSA 5.9

EEM: 2.5x2.7mm

RCA-P

88mm

Strategy: Full metal jacket stenting

2.5x3.0; CSA 5.9

EEM: 2.5x2.7mm

Full metal jacket3rd DES 3.0/32mm, 16 atm Final angiography

2009 Tainan, Taiwan

RCA-DRCA-P

12 months later

2010 Tainan, Taiwan

Noh HJ, et al.

Noh HJ, et al.

IMH

IMHIMH

After

cutting

L’t, transradial, JR4 catheter

2010 Tainan, Taiwan

66M, typical angina with Tl scan: inferior wall myocardial ischemia.

DM, HCVD, Dyslipidemia.

Mild angina, p’t refused CABG

2010 Tainan, Taiwan

Next day (No angina, cardial enz: np)

2010 Tainan, Taiwan

Transfemoral, 6F, SCR 4 GC,

Fielder FC GW in 1.5mm O-T-W balloon catheter

2010 Tainan, Taiwan

1.5 mm POBA

2010

Tainan

Taiwan

No IVUS, contrast injection by O-T-W BC

2010 Tainan, Taiwan

2.5/20 mm POBA (3-8 atm)

2010 Tainan, Taiwan

Tsunami 2.5/24 mm stenting

2010 Tainan, Taiwan

Final

2010 Tainan, Taiwan

46F, angina for 16 hrs, Tn-I 16.8ng/dl

no CAD risk factor

2013 Tainan, Taiwan

POBA

2013 Tainan, Taiwan

2.5/32 mm BMS, 12 atm

2013 Tainan, Taiwan

after stenting Initial

2013 Tainan, Taiwan

Spontaneous coronary artery dissection

2013

Tainan

Taiwan

an initial conservative approach “watchful waiting strategy”

for stabilized patients with SCAD

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

☺ Thanks for your attention ☺

64M, unstable angina for 10 days SYNTAX score: 12

crescendo angina on exertion

Tainan, Taiwan. 2015

OCT without pre-dilatation

Tainan, Taiwan. 2015

1.5/20 mm-POBA, then OCT

Tainan, Taiwan. 2015

OCT

Tainan, Taiwan. 2015

NC Quantum 4.5/20mm, 12 atm

Tainan, Taiwan. 2015

OCT

Tainan, Taiwan. 2015

IVUS

Tainan, Taiwan. 2015

Omega 4.5/24mm, 12 atm

Tainan, Taiwan. 2015

IVUS

Tainan, Taiwan. 2015

OCT

Tainan, Taiwan. 2015

NC Quantum 5.0/12mm, 12 atm

Tainan, Taiwan. 2015

OCT and final angio

Tainan, Taiwan. 2015

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