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Extraplaque Blood Withdrawal Stenting: A Miraculous Cure for Subintimal Hematoma

February 2024
1557-2501
J INVASIVE CARDIOL 2024;36(2). doi:10.25270/jic/23.00175. Epub February 9, 2024.

We report the Extraplaque Blood Withdrawal stenting technique to treat chronic total occlusion percutaneous coronary intervention (CTO PCI)-induced extraplaque hematoma.

A 51-year-old man presented with stable angina and previously failed right coronary artery (RCA) CTO PCI. During RCA CTO PCI (Figure 1), the wire was inserted into the extraplaque space (Figure 2, Video 1). Intravascular ultrasound (IVUS) showed a hematoma (Figure 3A, Video 2). Live 3-dimensional tip detection IVUS wiring was successful (Figure 4, Video 3). A FineCross microcatheter (Terumo) was placed over the first wire into the extraplaque space and blood was withdrawn by connecting a negative indeflator to the microcatheter. Stents were deployed (Figure 5) and postdilated. Post-IVUS showed almost complete resolution of the hematoma (Figure 3B, C; Video 4) with good results (Figure 6, Video 5).

There is increasing use of subintimal techniques in CTO PCI with the use of the Stingray System (Boston Scientific), ReCross microcatheter (IMDS), antegrade fenestration techniques, and IVUS-guided wiring. Subintimal transcatheter withdrawal was used for the Stingray1 and rescuing spiral dissection after stenting.2 This is an excellent complimentary technique to IVUS-guided wiring and other subintimal tracking techniques in CTO PCI.

 

Figure 1A. Right coronary artery chronic total occlusion
Figure 1A. Right coronary artery chronic total occlusion in left anterior oblique view with distal true lumen (green arrow). ​​​​

 

Figure 1B. Right coronary artery chronic total occlusion
Figure 1B. Right Coronary artery chronic total occlusion in right anterior oblique view with distal lumen (green arrow). ​​​​​​
Figure 1C. Right coronary artery chronic total occlusio
Figure 1C. Right coronary artery chronic total occlusion in left anterior oblique view with retrograde injection late filling with distal lumen (green arrow).
Figure 2. Wire in extraplaque space
Figure 2. Wire in the extraplaque space.
 
Figure 3. (A) Large extraplaque hematoma.
Figure 3A. A large extraplaque hematoma (green arrows). 
Figure 3. (B) no hematoma after stenting
Figure 3B. No hematoma after stenting.
Figure 3C. small residual hematoma after stent (yellow arrows).
Figure 3C. A small residual hematoma after stent (yellow arrows).

 

Figure 4. (A) Intravascular ultrasound (
Figure 4A. Intravascular ultrasound (IVUS)-guided wiring with extraplaque IVUS (yellow arrow) and a true lumen wire (green arrow)
Figure 4B. IVUS in extraplaque space
Figure 4B. Intravascular ultrasound in the extraplaque space (green arrow) and a wire in true lumen (yellow arrow).

 

Figure 5.  Extraplaque blood withdrawal stenting
Figure 5. Extraplaque blood withdrawal stenting with an extraplaque microcatheter (yellow arrow) during stent inflation.

 

Figure 6. Final angiogram
Figure 6. Final angiogram.

 

Affiliations and Disclosures

From the Prince of Wales Hospital, Chinese University Hong Kong, Hong Kong.

Disclosures: The authors report no financial relationships or conflicts of interest regarding the content herein.

Address for correspondence: Eugene B. Wu, Dept of Medicine and Therapeutics, Prince of Wales Hospital, Ngan Shing Street, Shatin, Hong Kong. Email: cto.demon@gmail.com

 

References

1. Smith EJ, Di Mario C, Spratt JC, et al. Subintimal TRAnscatheter Withdrawal (STRAW) of hematomas compressing the distal true lumen: a novel technique to facilitate distal reentry during recanalization of chronic total occlusion (CTO). J Invasive Cardiol. 2015;27(1):E1-4.

2. Sumiyoshi A, Okamura A, Iwamoto M, et al. Aspiration after sealing the entrance by stenting is a promising method to treat subintimal hematoma. JACC Case Rep. 2021;3(3):380-384. doi: 10.1016/j.jaccas.2021.01.004


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