Author + information
- Received August 9, 2017
- Accepted August 30, 2017
- Published online December 4, 2017.
- Satoru Mitomo, MDa,b,
- Francesco Giannini, MDa,b,
- Luciano Candilio, MDa,b,c,
- Antonio Mangieri, MDa,b,
- Daisuke Hachinohe, MDa,b,
- Azeem Latib, MDa,b and
- Antonio Colombo, MDa,b,∗ ()
- aUnit of Cardiovascular Interventions, IRCCS San Raffaele Scientific Institute, Milan, Italy
- bVita-Salute San Raffaele University, Milan, Italy
- cDepartment of Cardiology, The Hammersmith Hospital, Imperial College London, London, United Kingdom
- ↵∗Address for correspondence:
Dr. Antonio Colombo, Unit of Cardiovascular Interventions, IRCCS San Raffaele Scientific Institute, via Olgettina 60, 20132 Milan, Italy.
A 70-year-old man underwent percutaneous coronary intervention for proximal right coronary artery (RCA) chronic total occlusion with implantation of 3 bioresorbable vascular scaffolds (Absorb, Abbott Vascular, Santa Clara, California) to the distal to proximal RCA and a 4.0/18-mm Ultimaster (Terumo, Tokyo, Japan) to the ostium. The procedure was complicated by Ellis type 3 coronary perforation, treated with a 4.0/18-mm polytetrafluoroethylene-covered stent (PCS) (Aneugraft, ITGI Medical, Or Akiva, Israel) (Figure 1A).
Follow-up coronary angiography 17 months later showed patent RCA, aneurysmal changes in the proximal segment (Figure 1B), and focal restenosis of PCS at the ostium; therefore, percutaneous coronary intervention was attempted. The lesion was prepared with 3.5-mm cutting balloon, following which the patient experienced chest pain with inferior ST-segment elevation on electrocardiography. Coronary angiography revealed critical in-stent narrowing extended distally to the initial lesion (Figure 1C), which was dilated with 2.5-mm semicompliant balloon (8 atm), with rapid symptom and electrocardiography resolution. Intravascular ultrasound showed intimal dissection and intrastent hematoma, which extended distally to the aneurysmal change (Figures 2A to 2C) and was treated with implantation of a 3.5/24-mm Ultimaster stent (Figure 1D). Final intravascular ultrasound confirmed complete lesion sealing of dissection and hematoma (Figures 2A’ to 2C’).
Intimal dissection after PCS implantation has been previously reported (1); however, this is the first case reporting intrastent hematoma. The relatively soft tissue of the neointima may represent the underlying mechanism favoring this rare phenomenon, in view of: 1) its homogeneous morphology without obvious fibrotic or calcified components; and 2) the absence of tissue connection between intrastent and extrastent through the struts due to the barrier of PCS. Therefore, intimal dissection caused by cutting balloon could extend distally along PCS surface and result in occlusive hematoma formation. Moreover, the hematoma stopped at the lesion with aneurysm due to absence of neointima on malapposed metal struts.
Dr. Latib has served on the advisory board for Medtronic; and has received honoraria from Abbott Vascular. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received August 9, 2017.
- Accepted August 30, 2017.
- 2017 American College of Cardiology Foundation