Coronary Intra-neointimal Hyperplasia Hematoma After High-Pressure Dilation

A 68-year-old man was admitted for unstable angina pectoris. Six months previously, he was treated with two zotarolimus-eluting stents (ZESs) (2.75×24.0mm and 3.50×18.0mm) implanted from the proximal left anterior descending artery (LAD) to the left main artery (LM), and one ZES (2.50×18.0mm) in the proximal left circumflex coronary artery (LCX) (T-stenting strategy). Repeat coronary angiography showed in-stent restenosis (ISR) in the ostial LCX (Figure 1A) which was treated using a 2.50×26.0mm drug-coated balloon, and then kissing balloon inflations with a 3.50×15.0mm non-compliant balloon in the LAD and a 2.50×12.0mm non-compliant balloon in LCX, both at 6atm. After final proximal optimization technique with a 3.50×15.0mm non-compliant balloon at 12atm, angiography showed that the LM appeared to have a new, moderate stenosis (Figures 1B and 1C, Online Videos 1 and 2). Intravascular ultrasound (IVUS) showed an intra-neointimal hyperplasia hematoma, which is a homogeneous in-stent structure with blood speckle in the false lumen and intima pushed inward to cause lumen compromise (Figure 1D, Online Videos 3 and 4). An additional everolimus-eluting stent (3.5×18.0mm) implantation successfully, compressing the hematoma (Figures 1E and 1F). The patient was free of clinical events for 4-years follow-up.