Abstract
Background
Stent-induced coronary intramural hematoma (IMH) can propagate within the vessel wall, compress the true lumen, and compromise coronary flow. Extensive coronary IMH remains difficult to manage when passive fenestration fails.Case summary
A 64-year-old man developed extensive IMH after drug-eluting stent implantation from the ostium to the midsegment of the left anterior descending artery. Cutting-balloon fenestration failed to decompress the hematoma, which propagated distally and eliminated a suitable landing zone. Intravascular ultrasound (IVUS)-guided tip detection enabled targeted wire puncture and microcatheter advancement into the subintimal space. The subintimal transcatheter withdrawal (STRAW) technique achieved immediate active decompression and true-lumen restoration, allowing successful completion with additional stenting.Discussion
Quantitative IVUS demonstrated a reduction in the hematoma-containing nonluminal compartment and an increase in true-lumen volume after STRAW, supporting IVUS-guided active decompression as a feasible bailout strategy.Take-home messages
The STRAW technique can provide active decompression for extensive IMH when conventional fenestration strategies fail. Successful hematoma decompression may restore the distal true lumen, secure a suitable landing zone, and optimize the extent of additional stent coverage.