Presenter
Obadah Aqtash, MD, Baylor Scott & White The Heart Hospital - Plano, Dallas, TX
Obadah Aqtash, MD, Baylor Scott & White The Heart Hospital - Plano, Dallas, TX
Title
STEP 1: REMAIN CALM
Introduction
Coronary perforation can be caused by various factors, including trauma from guide wires or catheters used during the procedure, or due to the use of devices such as stents. It can also occur spontaneously due to underlying conditions that weaken the arterial wall, such as atherosclerosis or arteritis. Clinical Case
An 82 year old male patient with medical history significant for non-obstructive coronary artery disease, hypertension, hyperlipidemia, diabetes mellitus type 2, and chronic obstructive pulmonary disease presented to an outside hospital complaining of chest pain. EKG showed normal sinus rhythm without ischemic changes. Laboratory work up was significant for elevated troponin. Patient was diagnosed as an NSTEMI and taken to the cath lab where he was found to have two-vessel coronary artery disease. Patient referred to our facility for complex intervention of right coronary artery. Procedure was complicated by two perforations following the use of a cutting balloon. Both perforations were treated with balloon tamponad using a ringer balloon. The lumen of the ringer balloon was wired allowing for the delivery of a drug coated stent through it which was eventually deployed. No more extravasation of blood was seen, and patient remained hemodynamically stable. TTE showed trace pericardial effusion. Patient was discharged the following day in stable condition.
Discussion
Coronary perforation is a serious complication that requires prompt recognition and management to prevent potential complications such as cardiac tamponade, hemodynamic instability, or damage to the heart muscle. The management of coronary perforation depends on the severity of the tear, the extent of bleeding, the location of the perforation, and the overall clinical condition of the patient. Various algorithms have been designed for the approach of coronary perforation. The use of a ringer balloon in our case allowed us to tamponade the perforations while allowing for blood to flow to the distal vessel. Despite having two significant perforations, the patient remained hemodynamically stable, no cover stent was needed, and only trace pericardial effusion was seen on echo.