PMC3205786_01
(A) Original picture of LAD, proximal-mid second diagonal demonstrating diffuse luminal narrowing (arrows) with increase in distal caliber. (B) Original picture of RCA (normal). (C) Current picture of LAD, smooth diffusely narrowed proximal-mid segment (white arrows), subtotal occlusion in midportion (TIMI 1-2 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).
hi-2011-2-e10-g001.jpg
PMC3205786_01_hi-2011-2-e10-g001.jpg
F1
This was thought to be secondary to diffuse moderate to severe luminal stenosis in the second diagonal vessel (Figure 1A and B, Figure 2). 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). There was also diffuse moderate to severe luminal narrowing in the distal RCA and its branches (Figure 1D).
Diseased proximal to mid second diagonal vessel on prior angiogram likely representing diffuse intramural hematoma (mistaken for routine atherosclerosis).
hi-2011-2-e10-g002.jpg
PMC3205786_01_hi-2011-2-e10-g002.jpg
F2
This was thought to be secondary to diffuse moderate to severe luminal stenosis in the second diagonal vessel (Figure 1A and B, Figure 2).
(A) Cross sectional IVUS, intramural hematoma (arrow). (B) Kissing technique for stenting of LAD, circumflex bifurcation. (C) CT angiogram of RCA, demonstrating intramural hematoma surrounding lumen in distal RCA (arrows). (D) Final post stenting angiographic images of LAD, circumflex.
hi-2011-2-e10-g003.jpg
PMC3205786_01_hi-2011-2-e10-g003.jpg
F3
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). 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). The final angiographic result was excellent in all vessels including the LAD (Figure 3D).