Side branch occlusion salvage after covered stent placement for left main perforation
Presenter
Teodora Donisan, MD, Mayo Clinic College of Medicine and Science, Rochester, MN
Teodora Donisan, MD1, Devika Kir, MBBS2, Mayra E. Guerrero, M.D., FSCAI3 and Rajiv Gulati, M.D. Ph.D., FSCAI1, (1)Mayo Clinic College of Medicine and Science, Rochester, MN, (2)Mayo Clinic, Rochester, MN, Rochester, MN, (3)Mayo Clinic Health System Rochester, Rochester, MN
Title
Side branch occlusion salvage after covered stent placement for left main perforation Introduction
Left main (LM) perforation is an infrequent but life-threatening complication of percutaneous coronary interventions (PCI). Use of covered stents may require jailing and occluding the left anterior descending (LAD) or left circumflex (LCx) side branches. We describe a technique for rescue of an occluded side branch relating to covered stent placement across the distal LM. Clinical Case
(at age 27), complicated with radiation-associated coronary artery disease (CAD) and chronic total occlusion (CTO) of the proximal right coronary artery (RCA). He was admitted to the hospital for upper gastrointestinal (GI) bleeding and developed recurrent angina and troponin elevation, so he underwent coronary angiography. He was found to have a 90% ostial LCx lesionsingle-stent approach (3.5 x 24 mm Synergy). The upfront two-stent bifurcation approach was not pursued given recent GI bleeding. Post-dilation of the ostial LCx was complicated with LM perforation, hypotensioThe perforation was immediately contained with a covered stent (4.0 x 15 mm Papyrus) deployed in the LM into the left anterior descending LAD, with return of spontaneous circulation. This stent covered the ostium of the LCx with no antegrade flow noted. Given hemodynamic stability and the known CTO of the RCA that filled retrograde through left-right collaterals from the LCx, we elected to rescue the vessel through fenestration of the covered stent. A Confianza Pro 12 guidewire and a Turnpike Spiral microcatheter were advanced across the covered stent within 30-45 seconds, using the prior LCx stent and the jailed wire as markers. A channel was successfully made, followed by easy removal of the jailed wire from the LCx, balloon angioplasty, and stent place(3.5 x 8 mm Onyx) across the ostium (TAP configuration), and then by a kissing balloon inflation in the LM-LAD and LM-LCX. Completion angiography demonstrated a good result without evidence of extravasation across the LM and with TIMI 3 flow in the LAD and LCx territories with preserved left to right collaterals. He was transferred to the cardiac intensive care unit and was extubated on post-procedural day 8. Repeat echocardiography at that time revealed an EF of 53% without pericardial effusion. Unfortunately, the patient died on post-procedural day 12 from multi-system organ failure, after the family opted for a comfort-focused route. Discussion
Left main perforation management can be particularly challenging given the potential requirement for covered stents that occlude a major branch. Rescue of an occluded side branch via fenestration of a single-membrane covered stent (Papyrus) is feasible using standard coronary equipment.