Title:
Challenges and Solutions in Managing Coronary Rupture
Introduction
This describes coronary artery rupture following PCI, a complication can lead to life-threatening consequences. Highlights the immediate management strategies, ballon tamponade, pericardiocentesis and stent deployment. Underscores the importance of prompt recognition and tailored management preventing adverse outcomes.
Clinical Case:
65-M hypertension, hyperlipidemia, no CAD. The patient presented with progressive angina radiating to shoulders. Vitals normal. Physical Examination: No signs of heart failure and normal cardiac examination. ECG: Sinus rhythm with no signs of STEMI or ischemia. Laboratory: Negative serial cardiac biomarkers (High sensitivity Troponin and Creatine Kinase), LDL 2.3 mmol/L. Normal Echocardiogram. Treatment: Aspirin 162 mg, Clopidogrel 300 mg, IV Heparin infusion, Metoprolol 25 mg PO BID and Atorvastatin 80 mg. Cath showed left coronary dominant with high-grade lesions in the proximal and mid LAD culprit for the presentation (90-95%). Mild non-obstructive disease elsewhere for medical management. The plan was to deploy one DES in the mid and one in the proximal portion and protect the second diagonal artery with a wire. LAD predilated with 2.5 mm balloon. 2.75 x 22 mm DES at 14 atm deployed in mid LAD encompassing the second diagonal. Following deployment, coronary rupture noted below the second diagonal. PCI balloon used to tamponade rupture. RFA obtained and JL introduced to the left coronary artery after disengaging EBU. Run-through wire advanced to the site of the balloon inflation. After deflating the balloon, attempted to cross with run-through but were unsuccessful. Run-through wire withdrawn and catheter. EBU repositioned in left main. After several minutes of balloon inflation, reduced flow at the site of the rupture noted, following additional inflation, the rupture sealed. We deployed a short, covered stent below the second diagonal to ensure that the rupture securely sealed. We deployed a third stent, 2.75 x 22 mm in proximal LAD expanded with 3.0 mm noncompliant balloon. OCT showed adequate deployment. The patient was hemodynamically stable without chest discomfort. TTE showed no effusion. The patient returned to the CICU, stable. Developed hypotension and effusion. Returned to the Cath Lab for pericardiocentesis and review. Angiography demonstrated ongoing leakage from the site of the previously placed covered stent. Pericardiocentesis done and 120ml blood removed restoring hemodynamics. Balloon inflation was performed without sealing the leak. Additional covered stent [2.5 x 15 mm-5 atm] inserted in LAD. Initially unsuccessful. 2.75 mm noncompliant balloon used at higher atmospheric pressure fully sealing the leak. Repeat Cath after 24 hours: No contrast leakage and the patient remained stable.
Discussion
Coronary Artery Rupture is a serious complication following PCI. It can lead to cardiac tamponade, a life-threatening if not addressed promptly. Covered Stents is a mechanical solution to seal and prevent persistent leaks. While covered stents are effective, in this patient, additional balloon inflations and covered stent were required to achieve optimal closure. Covering side branches should avoided as possible when landing covered stents. Optimize vessel sizing pre-PCI (IVUS/OCT) and avoidance of aggressive post-dilatation in fragile vessels is key.