Intravascular Ultrasound Helps Differentiate

Coronary Mural Hematoma from Dissection

Wen-Hsiung Lin, Jui-Peng Tsai, Kuang-Te Wang, Yung-Chih Chen and Hsiao-yang Cheng

Intravascular ultrasound (IVUS) is a safe, accurate, and reproducible method of detecting vessel wall structure and

disease. In this case, we describe a 75-year-old female with hypertension and effort angina. Coronary arteriography

revealed critical stenosis in the distal right coronary artery (RCA), and intravascular ultrasound (IVUS)

demonstrated spontaneous dissection flap. A significant dissection-like lesion developed at the distal part of the

lesion after ballooning and stenting. Another stent was used to cover the edge dissection. The dissection-like lesion

extended proximally and distally and was complicated with inferior wall myocardial infarction. IVUS revealed

coronary mural hematoma which compromised the vessel lumen. We used stents to maintain adequate coronary

lumen and flow. One week later, follow-up angiography demonstrated patent RCA. The patient was discharged and

has had no symptom until now. Using angiography, it is difficult to differentiate coronary mural hematoma from

dissection. IVUS can provide valuable information in this situation.

Key Words: Intravascular ultrasound � Coronary mural hematoma

INTRODUCTION

Contrast coronary arteriography is limited in its abil-

ity to quantify the extent or distribution of atherosclero-

sis or to identify changes within the vessel wall over

time. Intravascular ultrasound (IVUS) lends insight into

dynamic changes before and after percutaneous coronary

intervention (PCI). IVUS is an imaging modality that

can bring a tomographic perspective to PCI and is capa-

ble of showing the arterial wall and the lumen of the cor-

onary arteries with high spatial resolution across the full

360-degree circumference of the vessel. Thus, it pro-

vides additional information beyond what is obtained

from angiography. The use of IVUS in cardiac catheteri-

zation laboratory has continued to evolve since its intro-

duction almost 15 years ago.1

IVUS may be used for several purposes during PCI:

(1) to assess plaque morphology and composition, quan-

tify vessel and plaque size and select the best devices for

PCI;2 (2) to confirm angiographic estimates of stenosis

severity; (3) to assess anatomical results and detect com-

plications, including dissections and residual minimal

cross-sectional area, after PCI;3 and (4) to assess stent

deployment and in-stent restenosis. In addition, IVUS

also can help differentiate between true and false coro-

nary aneurysm and between coronary dissection and mu-

ral hematoma like this case.

CASE REPORT

A 75-year-old female with a history of regularly

controlled hypertension and chronic obstructive pulmo-

nary disease for 20 years was admitted with effort an-

gina. Echocardiography had not shown obvious regional

wall motion abnormality, and patient could not tolerate

39 Acta Cardiol Sin 2009;25:39�42

Case Report Acta Cardiol Sin 2009;25:39�42

Received: December 5, 2007 Accepted: April 11, 2008

Division of Cardiology, Department of Internal Medicine, Mackay

Memorial Hospital, Taitung, Taiwan.

Address correspondence and reprint requests to: Dr. Jui-Peng Tsai,

Division of Cardiology, Department of Internal Medicine, Mackay

Memorial Hospital, 1, Lane 303, Changsha Street, Taitung, Taiwan.

Tel: 886-89-310150 ext. 543; E-mail: briannlin@pchome.com.tw

stress test due to degenerative disease of legs and mark-

ed exertional dyspnea. Coronary arteriography revealed

significant type B1 lesion on the distal right coronary ar-

tery (RCA) (Figure 1A) and insignificant lesion at the

left coronary artery.

The RCA was engaged with a 6 Fr JR5 guiding cath-

eter, and a floppy guidewire (Runthrough NS�) was in-

serted into the posterior lateral branch (PLV) of the

RCA. IVUS imaging of the lesion showed a cross-sec-

tional diameter of about 4.5~5.0 mm, and eccentric large

atheroma with 78� stenosis, and spontaneous plaque

dissection (Figure 1B) was noticed. The culprit lesion

was dilated with a Fortis� (non-compliance balloon 4.0

� 13 mm) at 14 atm. After balloon angioplasty, there was

46� residual stenosis, and a Driver� stent (4.0 � 15 mm

Medtronic�) was deployed at 14 atm in the distal RCA.

Post- dilatation was done with a Fortis� (non-compli-

ance balloon 4.0 � 13 mm) at 18 atm. Angiography re-

vealed a significant dissection-like lesion in the distal

stent area (Figure 1C), so we put another Driver� stent

(4.0 � 12 mm Medtronic�) at 9 atm and post-dilated with

a Fortis� (non-compliance balloon 4.0 � 13 mm) at 20

atm. Unfortunately, a new proximal lesion happened and

compromised the vessel lumen (Figure 1D). IVUS dem-

onstrated coronary mural hematoma and large atheroma

had compromised the vessel lumen and intact intima

without obvious dissection flap (Figure 2A). So we

chose a Driver� stent (4.0 � 24 mm Medtronic�) and de-

ployed at a lower pressure of 10 atm to maintain the lu-

men. The coronary mural hematoma continued to prog-

ress distally (Figure 2B) and caused distal RCA nearly

total occlusion resulting in inferior wall MI. Isoket 2 mg

intracoronary injection was tried, and the response was

poor. IVUS imaging had different finding from angio-

graphy and noticed a coronary mural hematoma at the

distal RCA to the PLV branch (Figure 2C). Another un-

Acta Cardiol Sin 2009;25:39�42 40

Wen-Hsiung Lin et al.

Figure 1. (A) Angiography revealed a significant type B1 lesion on the distal RCA. (B) IVUS of the lesion showed diameter of about 4.5~5.0 mm,

eccentric large atheroma and spontaneous plaque dissection. (C) Angiography found significant dissection-like lesion in the distal stent area. (D) A

proximally new lesion had happened and compromised the vessel lumen.

dersize Driver� stent (3.0 � 30 mm Medtronic�) was de-

ployed at lower pressure of 9 atm in the RCA (D- >

PLV) to keep the lumen patent (Figure 2D). After the

procedure, the patient’s symptoms improved and electro-

cardiogram revealed resolution of ST segments. The pa-

tient’s peak cardiac enzymes were CK: 354 U/L, CK-

MB: 37.7 U/L and troponin I: 11.2 ng/ml. One week

later, follow-up angiography and IVUS demonstrated

patent RCA with mild absorption and organization of

coronary mural hematoma. This patient was then dis-

charged, and has had no symptoms until now.

DISSCUSSION

Intermediate lesion presents a challenging task in

decision-making for revascularization and can be partic-

ularly troublesome in patients whose symptomatic status

is difficult to evaluate. This patient had typical effort an-

gina, but her echocardiography revealed normal wall

motion. In this situation, stress test was a good option.

Because she suffered from degenerative disease of the

legs and marked exertional dyspnea, the patient could

not tolerate treadmill test, and myocardial perfusion scan

is not available in Taitung. In addition to coronary

angiography, IVUS can assist decision-making, and in

combination with fractional flow reserve (FFR) is better

to detect significant stenosis than IVUS image alone.

Measurements of FFR and coronary flow reserve using

miniaturized sensors have proved useful in identifying

lesions of hemodynamic significance.4,5 We did not have

FFR, but the patient’s IVUS image had significant steno-

sis and vulnerable plaque, so angioplasty was indicated.

We treated her culprit lesion with balloon angio-

41 Acta Cardiol Sin 2009;25:39�42

Coronary Mural Hematoma or Dissection

Figure 2. (A) IVUS demonstrated mural hematoma and large atheroma had compromised vessel lumen. (B) Mural hematoma had progressed and

compressed distal lumen. (C) IVUS noticed mural hematoma at the distal RCA to PLV branch. (D) Angiography showed patent RCA and normal

coronary flow.

plasty and stenting. Coronary angiography extremely

mimiked coronary residual dissection after the first

stenting. IVUS did not found dissective intima, but we

still treated the new finding of angiography as edge dis-

section, covering it with another stent and post-dilatated

with high pressure for full expansion of stent. Unfortu-

nately, a new proximal lesion happened and compro-

mised the vessel lumen.

Coronary dissection is the most common reason for

acute arterial closure during PCI and can result in seri-

ous complications including death, myocardial infarc-

tion, and emergent bypass surgery. In addition, residual

dissection after stenting remains a risk factor for sub-

acute stent thrombosis in the DES era.6 For detection of

dissections, IVUS is a more sensitive imaging modality

than angiography. The circumferential and the longitudi-

nal extent of coronary dissections can be better appreci-

ated by IVUS. Whenever there is an indication for

stenting, IVUS imaging usually reveals involvement of a

longer arterial segment than can be appreciated angio-

graphically. This additional involvement may be particu-

larly important in cases of bailout stenting for threatened

acute closure, in which it is critical to cover the entirety

of the dissected segment.

In present case, if we still believed empirical dissec-

tion on angiography and had not been alert to check

IVUS after stenting, the mural hematoma would have

progressed to compromise coronary flow and the worst

result would have been acute closure of coronary flow

threatening the patient’s life. Management between coro-

nary dissection and mural hematoma is very different.

The treatment of dissection is used appropriate-size stent

and apposition to cover dissection, but the goal of mural

hematoma is use of stent to keep patent lumen and main-

tain adequate coronary flow.

The other problem is that plaque burden had not

been accurately evaluated when we chose the stent size.

After high pressure balloon dilatation, the massive

plaque burden had migrated to the proximal part and in-

duced mural hematoma due to barotrauma. Mural hema-

toma in this case results from large amount of atheroma

and treatment with high-pressure dilatation. Cross-sec-

tional area stenosis of IVUS is distinct from diameter

stenosis obtained by angiography because it does not use

reference segments, unlike angiography.7,8 IVUS can

more accurately evaluate plaque burden than angio-

graphy.

In conclusion, if there is massive atheroma detected

by IVUS, the stent should be mildly undersized and ap-

propriate pressure should be used to prevent plaque

shifting and mural hematoma. In addition, if angio-

graphy reveals atypical dissection-like lesion, IVUS

should be done to exclude mural hematoma. If mural

hematoma has happened and coronary flow is normal,

observation may be a good option. If a lesion is not well

assessed before PCI, the result of angioplasty can be

worse than with conservative treatment by medication.

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