2023 Scientific Sessions

Title

Left Main PCI Nightmares In The Cath Lab

Introduction

Ostial left main (LM) lesions confer high mortality and challenges during intervention. Surgery remains the mainstay of treatment. However, PCI can be performed on a case-by-case basis in high surgical risk patients. Here we present a case of an ostial LM PCI complicated by main vessel coronary perforation and cardiac tamponade

Clinical Case

A 83-year-old female with hypertension, hyperlipidemia presents with CCS III angina. Coronary angiogram showed 80% ostial LM, 60% ostial LAD and 80% ostial RCA lesions. CT surgery was consulted for CABG evaluation. Due to prohibitive surgical risk and shared decision making with the patient, high-risk PCI of LM was preferred.

Impella CP was inserted due to an unprotected LM via right femoral approach. Using a 7Fr EBU 4 guide catheter we advanced a Cougar guidewire into the distal LAD. This was challenging due to the acute angulation and tortuosity of the vessel. IVUS showed eccentrically calcified ostial LM and LAD. The proximal reference diameter was 4.2mm. We predilated with a 4mm non-compliant(NC) balloon and delivered a 4x24mm Synergy DES extending upto the ostial LM. IVUS showed underexpansion. Postdilation was performed with a 5mm NC balloon. The patient started complaining of chest pain. She was found to have an Ellis type III perforation at the LAD/circumflex bifurcation.

4mm NC balloon was used to tamponade the perforation site. CT surgery was informed for backup. Using a second left femoral 8Fr access, a guidewire was advanced into the circumflex via ping pong guide catheter technique. Then we advanced a 4x20mm Papyrus covered stent extending upto the ostium of the LAD and postdilated it. The patient was noted to be hypotensive despite Impella. Vasopressors were initiated and pericardiocentesis of 1L frank blood was performed. Auto-transfusion was initiated via left femoral vein. The perforation had not sealed entirely. Hence, a salvage double barrel technique was performed. A 3x15mm Papyrus covered stent from ostial LAD into ostial LM was deployed. A 3x15mm Papyrus covered stent was placed into the ostial LCx extending into the LM. This sealed the perforation entirely.

Vitals and pressor requirements improved. Right heart catheterization showed no concern for shock and Impella was explanted since protamine had been administered. Bedside echo did not show re-accumulation of pericardial effusion. She was transferred to the ICU and discharged on day 4. Almost two years later, she continues to follow up in clinic and remains asymptomatic.

Discussion

In retrospect, our case highlights several learning points. Angiography grossly underestimated the severity and calcified nature of the ostial LM lesion, which was better appreciated on IVUS. The culprit for perforation was high pressure inflation of oversized postdilation balloon. A favorable outcome was achieved due to protected LM, rapid identification, immediate balloon tamponade, obtaining a second access, ensuring guidewire position, collaborating with a second operator and having a surgeon on backup. Further steps included prompt management of hemopericardium, sealing the perforation with covered stents via bailout double barrel technique, autologous transfusion, assessment of hemodynamics and reversal of anticoagulation upon equipment removal.