Coronary artery dissection can impair coronary blood flow primarily due to an intramural hematoma (IMH) rather than luminal obstruction caused by an intimal flap, which makes percutaneous coronary intervention (PCI) challenging. Cutting balloon (CB) angioplasty has been proposed as a method to fenestrate the intima and decompress the IMH, although direct confirmation using intravascular imaging is rarely reported.
A 46-year-old man presented with an inferior ST-segment elevation myocardial infarction. Emergency coronary angiography revealed a critical lesion in the distal right coronary artery (RCA) with tapering at the far end. After crossing the lesion with a guidewire, coronary flow deteriorated, and angiography revealed an extensive spiral dissection extending retrogradely to the RCA ostium. No IVUS catheters were available. Optical coherence tomography (OCT) confirmed the wire was positioned in the true lumen and revealed pan-arterial IMH compressing the true lumen along the RCA (Figure 1 and Video 1).
To stabilize the proximal entry and protect the ostium, a drug-eluting stent was implanted at the RCA ostium. Distal flow did not recover, consistent with a persistently pressurized IMH. Sequential CB angioplasty was performed on the mid and distal segments of the RCA, successfully restoring TIMI 3 flow.
Post-procedural OCT revealed multiple linear intimal disruptions connecting the true and false lumens, consistent with successful IMH fenestration (Figure 2 and Video 2).
This case provides OCT evidence that CB angioplasty restores coronary flow in dissection by fenestrating and decompressing the IMH. Imaging-guided strategies may allow flow restoration while limiting unnecessary stent length in selected high-risk coronary dissections.
Patient consentInformed consent was obtained from the patient for publication of the case details and associated media.
Declaration of generative AI and AI-assisted technologies in the writing processDuring the preparation of this work the authors used ChatGPT (OpenAI) to assist with language editing and clarification of wording during manuscript drafting. After using this tool/service, the authors reviewed and edited the content as needed and take full responsibility for the content of the published article.
FundingThe authors received no specific grant from any funding agency, commercial entity, or not-for-profit sector.
Conflicts of interestThe authors declare no conflicts of interest related to this case.
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