A unique bailout strategy for coronary artery dissection accompanying longitudinal hematoma

Coronary artery dissection (CAD) is a common phenomenon following balloon dilatation in percutaneous coronary intervention (PCI) [1]. While most CAD can be managed safely, it is challenging to manage CAD accompanying longitudinal hematoma. Except for using a cutting balloon to make a re-entry [2], full-cover stenting until the end of hematoma is a standard strategy, because an uncovered hematoma would cause ischemia [3]. Although the development of the guide-extension catheter made full-cover stenting easy in most cases [4], it is technically impossible to perform full-cover stenting when a longitudinal hematoma extends to the far distal part of the coronary artery.
A-72-year-old man with effort angina underwent PCI to the stent distal lesion of the left anterior descending artery (LAD) (Figure 1 A). He received a 2nd generation drug-eluting stent (DES) (2.5 × 18 mm) to the LAD 3 years ago. In PCI, intravascular ultrasound (IVUS) revealed that the target was around the distal edge of the previous stent. We performed pre-dilatation using 2.0 × 15 mm ScoreFlex NC (Orbusneich, Hong Kong, China) (Figure 1 B), and then inflated the 2.0 × 15 mm Sequent Please Neo (B. Braun, Melsungen, Germany) with 6 atm. Suddenly, the patient complained of chest pain with ST-segment elevation in leads V2-6. Angiography showed slow flow in the distal part of the LAD. IVUS revealed CAD (Figure 1 C) accompanying longitudinal hematoma (Figure 1 E). Because the longitudinal hematoma extended to the far distal part of the LAD, we abandoned the full-cover stenting strategy, and decided to apply a stent to cover the entry point of the CAD. We deployed a 2.0 × 26 mm Resolute Onyx stent (Medtronic, Dublin, Ireland) to make an overlap with the previous stent (Figure 1 F). Since the injection of contrast medium would exacerbate dissection, stent implantation was performed without contrast medium. After stent placement, the ST elevation gradually resolved, and the chest pain also improved. IVUS after stent implantation confirmed the expansion of the deployed stent and the uncovered hematoma in the distal segment of the LAD. After watchful waiting for more than 15 min in the catheter laboratory, we closed the PCI without final angiography. We confirmed no elevation of creatine kinase or creatine kinase muscle brain during the following days. The patient was discharged on day 6 without any complications. One month after the PCI, angiography showed excellent coronary flow (Figure 1...


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