Comparative Outcomes of Novel Small Balloon Low‐Pressure Pullback and Traditional Management for Coronary Intramural Hematoma Complicating PCI

BACKGROUND AND AIMS: The management of percutaneous coronary intervention (PCI)-related coronary intramural hematoma (CIMH) is debated. Conventional strategies-additional stenting with/without cutting balloon (AS/CB) or conservative management (CM)-have limitations. The small balloon low-pressure pullback technique (SBLP) is a newer option, but comparative evidence is limited. This study compared in-hospital and long-term outcomes among AS/CB, CM, and SBLP. METHODS: In this retrospective cohort study, 181 patients who developed CIMH during PCI between January 2022 and December 2025 were enrolled. Patients were managed with AS/CB (n = 109), CM (n = 20), or SBLP (n = 52). Primary endpoints included myocardial injury biomarkers (troponin I), cardiac function recovery (LVEF), stent utilization, hospitalization stay and costs, and major adverse cardiovascular events (MACEs). RESULTS: Post-procedural troponin I levels decreased significantly in the AS/CB and SBLP groups (all p < 0.05) but increased significantly in the CM group (p < 0.05). LVEF improved postoperatively in the AS/CB and SBLP groups (all p < 0.05) but decreased in the CM group (p < 0.05). Hospital stay was shortest with SBLP (median 5.0 days) versus CM (10.0) and AS/CB (7.0). Stent use was highest with AS/CB (total length 77.0 mm; 3.0 stents) versus others (p < 0.05). Over 15.1 months, MACE incidence was lowest with SBLP (7.7%) versus AS/CB (29.4%) and CM (50%; p < 0.001). Adjusted hazard ratios confirmed lower MACE risk: SBLP versus CM, HR 0.060, 95% CI 0.018-0.210, p < 0.001; AS/CB versus CM, HR 0.385, 95% CI 0.174-0.853, p = 0.019. CONCLUSION: SBLP shows potential benefits over conventional CIMH management, with improved cardiac function, shorter hospitalization, fewer stents, and better long-term outcomes.