intra- and extra - mural hematomas are known complications after percutaneous coronary intervention ( pci).1 - 4 ) based on an intravascular ultrasound ( ivus ) examination , an intramural hematoma represents an accumulation of blood between the internal ( iem ) and external elastic membranes ( eem ) within the medial space , whereas dilution and/or dissemination of blood throughout the adventitia are observed in extramural hematomas.5)6 ) although one - third of patients with chronic total occlusion ( cto ) have intramural hematomas during successful recanalization,7 ) no cases of combined intramural and extramural hematomas have been reported . we report a case of combined intramural and extramural hematomas during successful recanalization of a cto lesion demonstrated by ivus , which was treated with long drug - eluting stents ( dess ) . a 51-year - old woman was admitted with effort - induced chest pain . she had hypertension , diabetes , and hypercholesterolemia for 7 years . a baseline electrocardiogram showed left ventricular hypertrophy by criteria and inverted t waves in the inferior leads and leads v4-v6 . an echocardiogram showed no regional wall motion abnormalities with preservation of the left ventricular ejection fraction . a 64 multi - slice computerized tomography showed significant stenosis in the mid - portion of the left anterior descending artery ( lad ) and total occlusion in the distal portion of the right coronary artery ( rca ) . similarly , a diagnostic coronary angiogram revealed diffuse narrowing of the mid - lad ( 70% ) and total occlusion of the distal rca . there was grade 2 collateral flow from the lad to the rca via the septal branch ( fig . 1 ) . the patient was initially scheduled to undergo pci for recanalization of the rca . the right coronary ostium was engaged with a 7-fr amplatz 4.0 guiding catheter and the left coronary ostium was cannulated with a 5-fr judkin catheter for the contralateral angiogram . with the support of a 1.5-mm over - the - wire balloon system ( boston scientific , natick , ma , usa ) , a pt ll ( boston scientific ) 0.014-inch guidewire was advanced . after failing the first guidewire passage , a miracle 3 g , 6 g , and 12 g guidewires ( asahi , seto , japan ) therefore , a parallel wire technique using miracle 12 g and conquest pro guidewires ( asahi ) was attempted . by this parallel wire technique , a conquest pro guidewire was advanced to the totally occluded lesion . following the angiogram , however , the tip of the conqest pro guidewire was shown to be placed outside of the vessel beyond the distal rca bifurcation without extravasation of contrast media ( fig . after repeated attempts to manipulate the guidewire , the conquest pro guidewire successfully entered the true lumen of the posterolateral ( pl ) branch and pre - dilatation with a voyager balloon ( 2.520 mm ; abbott , santa clara , ca , usa ) was performed . at this point , ivus ( atlantis sr pro 40 mhz ; boston scientific ) was performed to obtain vessel information as well as identification of pci complications . the qualitative ivus finding showed the following : 1 ) a hypo - echogenic , inhomogeneous , lobulated mass within the lumen in the distal rca , suggesting an intraluminal thrombi ( fig . 2a and b ) , 2 ) a crescent - shaped , hypo - echogenic , accumulation of contrast media with displacement of the iem into the lumen in the distal rca , suggesting an intramural hematoma ( fig . 2b and c ) , 3 ) an eccentric inhomogeneous echogenecity , consistent with accumulated blood , in the proximal portion of the pl branch to the distal bifurcation site , and a probable communication site between the lumen and adventitia , suggesting an extramural hematoma ( fig . 2d - g ) , and 4 ) an intimal dissection to the media from 3 to 6 o'clock in the mid - portion of the pl branch ( fig . a quantitative ivus measurement showed that a total lesion length from the pl branch to the mid - rca was 50 mm and the distal reference diameter was 2.8 mm . for entire coverage of the occluded lesion , as well as intra- and extra - mural hematomas , 2 taxus stents ( 3.028 mm and 2.7528 mm ; boston scientific ) the final coronary angiogram demonstrated no residual lumen narrowing with thrombolysis in myocardial infarction 3 flow ( fig . 3 ) . a post - stenting ivus revealed well - opposed stent struts to the vessel wall and a 4.66 mm minimal stent area ( msa ) ( fig . 3c ) . because the msa was located at the distal bifurcation site with co - existing intra- and extra - mural hematomas and there was a risk of coronary rupture , no further intervention , such as adjunctive balloon dilatation , was performed . the next day , 2 additional taxus stents ( 3.028 mm and 2.7528 mm ) were deployed with an overlapping technique for the mid - lad lesion . for antiplatelet therapy , the patient received a triple regimen , including aspirin ( 100 mg once daily ) , clopidogrel ( 75 mg once daily ) , and cilostazol ( 100 mg twice daily ) . the fourth day of admission , she discharged without any procedure - related complications . during the 3-year clinical follow - up , the patient remained stable and had no evidence of a cardiovascular event . after coronary intervention , several complications , including dissection , vasospasm , and hematomas may occur within the target vessel.3)8)9 ) among the complications , intra- or extra - mural hematomas have been diagnosed infrequently because of the absence of definitive angiographic findings . because ivus can provide high - quality , morphologic information regarding the coronary arteries before and after coronary intervention , ivus permits detection of intra- or extra - mural hematomas during an interventional procedure . an intramural hematoma after pci is defined as an accumulation of blood within the medial space displacing the iem inward and the eem outward , with or without identifiable entry and exit points.6 ) in contrast , an extramural hematoma is defined as an accumulation of blood outside the arterial wall in the adventitia tissue and presents with an echo - dim pattern due to the dilution of the red blood cells and dissemination throughout an echogenic adventitia.5 ) an ivus study reported a 6.7% incidence of intramural hematomas in 905 patients with 1,025 lesions undergoing pci.1 ) because one - half of intramural hematomas involve the distal reference artery and/or luminal narrowing , intramural hematomas are sometimes considered to represent coronary spasm.1 ) the possible mechanism underlying intramural hematomas involves blood entering the medial space via a dissection point along with longitudinal spread to a more normal vessel wall.1)10 ) one - third of intramural hematomas detected by ivus show no abnormalities on coronary angiogram ; however , intramural hematomas are associated with a high rate of non - q - wave myocardial infarction and thus need repeat revascularization to prevent sudden death.1 ) therefore , performing an ivus examination plays a major role in the detection of intramural hematomas during pci.1 ) fujii et al.7 ) reported the ivus morphologic features of 67 ctos just after guidewire passage or small balloon inflation . this study demonstrated that multiple small calcium deposits and intramural hematomas were the most common findings during cto intervention . presumably , a stiff guidewire likely penetrates into the medial space at the junction of a disease - free wall , translating into a higher chance of intramural hematoma formation.7 ) similarly , in the presented case , a stiff guidewire entered into the medial space in the distal portion of the rca and penetrated into the eem at the rca bifurcation site , resulting in intra- and extra - mural hematomas . compared with an intramural hematoma , the incidence and mechanism of extramural hematomas are not well established . mahr et al.2 ) reported a case of an extramural hematoma causing a reduced distal vessel diameter after coronary stenting , which was treated with another coronary stent . similar to the mechanism of an intramural hematoma , dissection into the adventitia plays a beginning point of blood entry , which can be detected by ivus . from a clinical standpoint , a therapeutic strategy for intra- and/or extra - mural hematomas is a major issue during pci . several cases of intra- or extra - mural hematomas after pci have been reported , which were successfully treated with coronary stenting.2)11 - 13 ) in our case , the blood entry site appeared as a dissection within the media and adventitia and resulted in combined intra- and extra - mural hematomas as detected by ivus , although there was no evidence of extravasation of contrast media into the pericardium by coronary angiogram . the final angiogram showed an acceptable result without any complications after successful coronary stenting , suggesting intra- and extra - mural hematomas were compressed and the entry site was sealed by the dess . ivus can identify intra- or extra - mural hematomas that can not be detected by coronary angiogram after pci in complex lesions .
an intramural hematoma is an accumulation of blood between the internal and external elastic membranes within the medial space , whereas an extramural hematoma is a dilution and/or dissemination of blood throughout the adventitia . 
 intra- and extra - hematomas are observed by intravascular ultrasound during percutaneous coronary intervention ( pci ) . 
 the patient described herein presented with angina pectoris . 
 her coronary angiogram showed diffuse narrowing of the mid - left anterior descending artery and total occlusion of the distal right coronary artery ( rca ) . 
 intra- and extra - mural hematomas developed during pci of the rca ; however , the lesions were covered successfully using long drug - eluting stents .