Case study: a coronary Type III perforation during left anterior descending CTO-PCI

Clinical presentation

• 71-year-old female
• Admitted for inferior-STEMI treated with primary PCI on RCA
• ID diabetes
• CKD (creat. 1,58 mg/dl; GFR 40 ml/min)
• TTE: Ejection fraction 50%, mid-distal inferior akinesia, moderate mitral regurgitation
• 2-days after primary PCI, patient was scheduled for left anterior descending CTO-PCI

Left anterior descending CTO

Left anterior descending CTO

Procedure

Double radial access with guiding catheter 6F JR 4.0 and sheatless 7.5F PB 3.5. Controlateral injection to check antegrade wire position via collaterals (Figure 4.1).

Antegrade guide wire position (Figure 4.1)

Antegrade guide wire position (Figure 4.1)

CTO crossed with Miracle 6g, after unsuccessful attempts with Sion and Pilot 150. Floppy wire in diagonal branch to improve support (Figure 4.2).

Guide wires to LAD and diagonal branch (Figure 4.2)

Guide wires to LAD and diagonal branch (Figure 4.2)

2.0 x 20 mm NC balloon predilatation (Figure 5.1)

Predilatation NC balloon (Figure 5.1)

Predilatation NC balloon (Figure 5.1)

Miracle exchanged with floppy wire to LAD. Guide wires position checked via controlateral injection (Figure 5.2).

Guide wires position via contralateral injection (Figure 5.2)

Guide wires position via contralateral injection (Figure 5.2)

NC 2.5 x 30 mm balloon predilatation and 2 DES implantation in overlapping (Figure 6.1).

Predilatation with NC balloon (Figure 6.1)

After overlapping post-dilatation, Type III coronary perforation and sudden cardiac tamponade occurred (Figure 6.2).

Type III perforation and cardiac tamponade (Figure 6.2)

Stop coronary flow as soon as possible with balloon inflation technique. Implementation of pericardiocentesis, no Protamine (Figure 7.1).

Quick pericardiocentesis with 6F femoral sheat and balloon dilatation to stop coronary flow (Figure 7.1)

Quick pericardiocentesis with 6F femoral sheat and balloon dilatation to stop coronary flow (Figure 7.1)

JR 4.0 guiding catheter exchanged with JL 4.0 to achieve left main (ping-pong) and position a parallel wire in left anterior descending (Figure 7.2). In the first wire we have the balloon, in the second wire a covered stent, but the perforation resolved only with balloon dilatation so we avoided, at this time to implant a covered stent.

JR 4.0 guiding catheter exchanged with JL 4.0 to achieve left main ping-pong (Figure 7.2).

JR 4.0 guiding catheter exchanged with JL 4.0 to achieve left main ping-pong (Figure 7.2).

After several minutes no contrast protrusion, the perforation appeared resolved, so the second wire in the JL catheter was removed and PCI completed with another DES implantation in proximal LAD (Figure 8.1).

Additional DES implanted to proximal LAD (Figure 8.1)

Additional DES implanted to proximal LAD (Figure 8.1)

The angiographic control showed mild perforation recurrence (Figure 8.2).

Perforation still present (Figure 8.2)

Implantation of the covered stent (Figure 9).

Covered stent implanted (Figure 9)

Final angiographic result

Final result with TIMI III flow, no leak (Figure 10)

Final result with TIMI III flow, no leak (Figure 10)