Intramural Hematoma and “Cuttering” as a Rescue Technique

Coronary dissections can be self-limiting or they can progress, generating an intramural hematoma (IMH). The false lumen resulting from the dissection can expand, increasing endoluminal pressure and compressing the true lumen, which reduces distal antegrade flow.

When dissections or hematomas are limited and do not affect the blood flow, the usual recommendation is conservative management. However, cases with compromised distal flow require interventions. These can be complex due to the difficulty of navigating the true lumen and the limitations of contrast use due to dissection progression. In some cases, there may be a need for techniques typically used for chronic total occlusion (CTO) recanalization, such as subintimal tracking and reentry, fenestration and reentry, or specific devices like the Stingray system or intravascular ultrasound (IVUS)-guided reentry.

Containing the IMH expansion is crucial. Case reports and series have suggested the use of cutting balloons (CB) for its management. Typically, operators select cutting balloons slightly smaller or equivalent (1:1) to the reference vessel diameter, which are inflated to nominal pressure to create fenestrations between the false and true lumen, thus relieving endoluminal pressure. 

In certain cases, conventional use of CB may be insufficient, and the hematoma progresses distally. This work aimed to present the initial results for an innovative technique called “Cuttering” (Cutting-Dottering Balloon). 

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A CB 1:1 to the reference vessel is advanced to the area of maximum lumen compression. It is inflated to its nominal pressure (6-9 atm) followed by subtle back-and-forth movements. If sliding is difficult, the balloon can be inflated partially at less atm, and multiple inflations may also be used.

Procedural success can be visually assessed via angiography or IVUS, observing changes in blood speckle intensity. In this study, the team from Humanitas Research Hospital and Ospedale Papa Giovanni XXIII (Italy) presented results from the first patients treated with this technique. 

The benefits of the Cuttering technique include concentrated force during sliding movements, progressive cutting, and the formation of microfractures. While the use of CB alone can restore TIMI III flow, in cases where this result is not achieved, the Cuttering technique may increase the chances of success. 

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In this small case series, restoration of TIMI III flow was achieved in 5 of the 7 treated patients, while the other two achieved TIMI II flow, with no significant clinical sequelae. The authors discourage the use of the Cuttering technique in calcified lesions or vessels with severe tortuosity due to the risk of perforation or serious vessel damage.

Conclusions

In cases where conventional inflation with cutting balloons is insufficient for the treatment of intramural hematoma, the Cuttering technique could be a viable option for hematoma drainage and coronary flow improvement.

Original Title: The “Cuttering (Cutting‐Dottering Balloon) Technique” for treatment of flow‐limiting coronary intramural hematoma.

Reference: Gasparini GL, Maurina M, Regazzoli D, Canova P, Leone PP, Mangieri A, Reimers B. The “Cuttering (Cutting-Dottering Balloon) Technique” for treatment of flow-limiting coronary intramural hematoma. Catheter Cardiovasc Interv. 2024 Sep 26. doi: 10.1002/ccd.31231. Epub ahead of print. PMID: 39323300.