Compressive Coronary Hematoma in an Elderly Woman Receiving Oral Anticoagulation Treated With Cutting Balloon Fenestration

BACKGROUND: Intramural hematoma (IMH) is an uncommon cause of acute coronary syndrome and may occur in elderly patients with vascular fragility receiving oral anticoagulation. CASE SUMMARY: ). OCT-guided cutting balloon fenestration in the posterolateral branch (3 inflations, 16 bar) restored TIMI flow grade 3 without stenting. On day 3, complete atrioventricular block with pauses of >7 seconds led to permanent pacemaker implantation. Systematic angiography on day 5 showed silent distal right coronary artery IMH extension, prompting anticoagulation discontinuation. At 3 months, complete healing was observed, followed by left atrial appendage closure. No events occurred during the 4-year follow-up. DISCUSSION: Selective OCT-guided fenestration enabled durable revascularization without stent implantation. TAKE-HOME MESSAGE: Cutting balloon fenestration provides favorable long-term outcomes in compressive IMH.