Optical Coherence Tomography Evaluation of Coronary Dissection and Intramural Hematoma

J INVASIVE CARDIOL 2019;31(1):E6.

Key words: cardiac imaging, intramural hematoma, NSTEMI

A 32-year-old female with elevated body mass index and no prior medical history presented with acute-onset central chest pain radiating to both arms. Electrocardiogram showed biphasic T-waves in the anterior leads and troponin level was elevated. Echocardiogram demonstrated preserved left ventricular function and no valvular abnormality. A diagnosis of non-ST elevation myocardial infarction (NSTEMI) was made. Coronary angiography revealed a smooth tapering stenosis in the mid left anterior descending (LAD) artery (Video 1), but no significant disease beyond (Figure 1, top center panel). The other coronary vessels were free of significant disease. Given her age and the somewhat unusual angiographic appearance, the LAD was further interrogated with optical coherence tomography (OCT). This revealed normal trilaminar vessel-wall architecture in the proximal and distal sections (Figures 1A and 1E; Video 2); however, there was an extensive intramural hematoma causing luminal compression (Figures 1B and 1D) corresponding to the angiographic stenosis. A small intimal tear extending only 1 to 2 mm in length was also identified (Figure 1B) as a likely entry point. There was no atherosclerotic plaque. This patient was managed conservatively and was discharged home on the third day with no further clinical issues. 

Classically, intramural hematomas comprise accumulation of blood within the media (between internal and external elastic laminae), although continuation with adventitia has also been described. They can be spontaneous (as described in this case) or iatrogenic, as described elsewhere. An entry point may or may not be present. Although identifiable on intravascular ultrasound, OCT offers superior characterization and exclusion of alternate diagnoses, such as plaque erosion. 

View the accompanying video series here.

From the James Cook University Hospital Middlesbrough, United Kingdom.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Williams reports proctoring fees from Abbott Vascular. Dr Austin reports proctoring and speaking fees from Abbott Vascular; speaking fees from Astra Zeneca. Dr Hayat reports no conflicts of interest regarding the content herein.

The authors report that patient consent was provided for publication of the images used herein.

Manuscript accepted August 20, 2018. 

Address for correspondence: Dr David Austin, The James Cook University Hospital, Marton Road, Middlesbrough, United Kingdom TS4 3BW. Email: david.austin@nhs.net