causes of intramural hematoma or spontaneous coronary dissection ( scd ) include a peripartum state , coronary vasospasm , connective tissue disease , chronic infection , post - percutaneous coronary intervention or stenting , and any condition that compromises the integrity of the arterial wall . the optimal treatment approach for intramural hematoma has not been well defined and discussion is limited to case reports . a 53-year old post - menopausal woman with a past medical history of hypertension and hyperlipidemia came to our attention four months prior to the current presentation with a non - st segment elevation myocardial infarction . this was thought to be secondary to diffuse moderate to severe luminal stenosis in the second diagonal vessel ( figure 1a and b , figure 2 ) . this was presumed to be routine branch vessel coronary disease and this was treated medically at that time . four months later , the patient presented with new onset refractory chest pain , anterior st depression and congestive heart failure with elevated biomarkers . angiography revealed diffuse moderate coronary stenosis in the proximal and mid - left anterior descending artery followed by a 99% occlusion in the mid lad with timi 2 flow and severely compromised first diagonal vessel ( figure 1c ) . interestingly , the second diagonal ostium which was previously diseased was now widely patent with no luminal narrowing ; this perhaps indicates a healed intramural hematoma or dissection in this branch vessel from four months before . there was also diffuse moderate to severe luminal narrowing in the distal rca and its branches ( figure 1d ) . in comparison to the angiogram performed four months earlier before , there appeared to have been a significant and diffuse progression of coronary luminal narrowing . initially , a small 2.25 mm balloon was used to dilate the subtotal mid lad occlusion at 68 atmospheres ( atm ) with complete balloon expansion at a low pressure of 12 atm , with no improvement in stenosis and no plaque shift into the side branch . in spite of complete balloon expansion given the dramatic progression in luminal narrowing and atypical response of the stenosis to balloon inflation , routine atherosclerosis was not suspected . there was no angiographic evidence of dissection , i.e. contrast hang - up or luminal linear opacity . intravascular ultrasound ( ivus ) was , therefore , performed to evaluate coronary luminal anatomy . ivus showed diffuse intramural hematoma with circumferential detachment of the intima from the media along the proximal two - thirds of the lad right up to the left main bifurcation ( figure 3a ) . surgical consultation was requested and an attempt at complex multi - vessel pci was recommended which was subsequently implemented . the rca was treated medically due to diffuse and distal branch vessel involvement precluding percutaneous intervention or bypass grafting . a total of four drug - eluting stents were used to revascularize the lad and circumflex vessel with a kissing v - stent technique for the lm , lad and circumflex ( figure 3b ) , due to milking of the intramural hematoma from the ostial lad to the ostial circumflex . a cardiac ct which was performed 24 h post stenting demonstrated widely patent stents and a reduction in vessel caliber of the distal rca with abnormal soft tissue adjacent to this segment , consistent with diffuse intramural hematoma with luminal compression ( figure 3c ) . although an unenhanced fine cut gated ct is not routinely performed at our institution prior to contrast administration , such a scan may have demonstrated high attenuation along the artery wall in this setting of intramural hematoma . the final angiographic result was excellent in all vessels including the lad ( figure 3d ) . laboratory investigations including ana , lupus inhibitor , rheumatoid factor and complement studies were unremarkable . 
 figure 1(a ) original picture of lad , proximal - mid second diagonal demonstrating diffuse luminal narrowing ( arrows ) with increase in distal caliber . ( c ) current picture of lad , smooth diffusely narrowed proximal - mid segment ( white arrows ) , subtotal occlusion in midportion ( timi 12 flow ) ( black arrow ) , no evidence of angiographic dissection . ( d ) current picture of rca , smoothly tapered distal rca , multiple severe occlusive lesions in distal branches ( arrows ) . ( a ) original picture of lad , proximal - mid second diagonal demonstrating diffuse luminal narrowing ( arrows ) with increase in distal caliber . ( c ) current picture of lad , smooth diffusely narrowed proximal - mid segment ( white arrows ) , subtotal occlusion in midportion ( timi 12 flow ) ( black arrow ) , no evidence of angiographic dissection . ( d ) current picture of rca , smoothly tapered distal rca , multiple severe occlusive lesions in distal branches ( arrows ) . figure 2diseased proximal to mid second diagonal vessel on prior angiogram likely representing diffuse intramural hematoma ( mistaken for routine atherosclerosis ) . diseased proximal to mid second diagonal vessel on prior angiogram likely representing diffuse intramural hematoma ( mistaken for routine atherosclerosis ) . 
 figure 3(a ) cross sectional ivus , intramural hematoma ( arrow ) . ( c ) ct angiogram of rca , demonstrating intramural hematoma surrounding lumen in distal rca ( arrows ) . ( c ) ct angiogram of rca , demonstrating intramural hematoma surrounding lumen in distal rca ( arrows ) . we present a novel case of multivessel diffuse intramural hematoma treated with selective percutaneous intervention . a high index of suspicion for intra - mural hematoma or dissection is required when atypical presentations of atherosclerosis or infarction are encountered . intravascular ultrasound and multi - slice ct are complementary and important multimodality imaging techniques when routine coronary angiography may not demonstrate dissection flaps . the true incidence of intramural hematoma and scd is unknown as patients may present with sudden cardiac death . however , post - pci , intramural hematomas have been diagnosed in up to 6.7% of cases with intravascular ultrasound guidance . not all risk factors for intramural hematoma or scd have been identified , but there appear to be four groups of patients who present with intramural hematoma or scd : women in the peri - partum period , atherosclerosis associated coronary hematoma , idiopathic cases ( including patients with connective tissue diseases , vasculitis , lupus erythematosus , extreme exercise , and also drug use ) , and post percutaneous coronary intervention ( pci ) . a new stent - edge lesion or milking of a de novo coronary lesion distally , proximally or into an adjacent branch or vessel has been described previously . single vessel spontaneous intramural hematomas have been described and previous therapies have included watchful waiting , as the healing process for these lesions may involve simple hemorrhage reabsorption as opposed to routine plaque healing . the typical vessel involved outside the post - pci setting is often relatively healthy to allow propagation of blood into the media without being impeded by calcific or fibrotic plaque . the diagnosis of scd is made through identification of a false coronary lumen on diagnostic imaging . angiography may fail to reveal a clear dissection flap and may not accurately delineate the extent of the dissecting hematoma . intramural coronary hematoma may simply appear as diffuse coronary luminal narrowing unless the integrity of the vessel wall can be evaluated directly . the use of ivus can provide a diagnosis of scd due to its ability to provide images of the coronary vessel layers . cardiac computed tomography ( ct ) has also been reported to be of value in identifying intramural hematoma / scd and may play a role in monitoring patients after definitive therapy . cardiac ct angiography offers a non - invasive evaluation of luminal patency as well as coronary anatomy , and may also help identify the extent of dissection and progression . the identification of scd is important in the setting of myocardial ischemia as classic management may differ from that of thrombotic coronary occlusion . although routine angiography is the main stay of diagnosis of scd or intramural hematoma , ivus and cardiac ct angiography are critical multimodality imaging methods which help in the accurate diagnosis and evaluation of the extent of coronary intramural hematoma and other atypical coronary pathologies . although there is no clear consensus on management of multivessel intramural hematoma or scd , the key principal of re - establishing coronary flow in the setting of ongoing ischemia holds true as in any acute coronary syndrome .
spontaneous coronary dissections are a well described entity which are often difficult to treat . 
 intramural hematoma is one type of coronary dissection . 
 previous case reports have described the treatment for angiographically visible dissection . 
 we describe the first report of diffuse intramural hematoma visualized only on intravascular ultrasound with no angiographically obvious evidence of dissection treated with multivessel drug eluting stenting . 
 this case highlights the importance of a high level of suspicion and atypical presentations of coronary dissection , and the use of multimodality imaging with intravascular ultrasound and computerized tomography for both diagnosis and therapy .