Coronary Artery Perforation with Effusion: A PCI complication case.
Kelechi Onyekachi Weze, MBBS, Johns Hopkins University, Baltimore, MD
Kelechi Onyekachi Weze, MBBS, Johns Hopkins University, Baltimore, MD
Keywords: Complications, Coronary, Drug-eluting Stent (DES), Hemodynamic Support and Occlusion Devices
Title
Coronary Artery Perforation with Effusion: A PCI complication case.
Introduction
Coronary perforation is a relatively rare but life-threatening complication of coronary interventions and mastery of its management is essential for the interventional cardiologist
Clinical Case
78 year old male with history of Hypertension and coronary artery disease (known LAD CTO and severe lesions of the mid left circumflex artery LCX and second obtuse marginal OM2) who presented for planned PCI of the LCX/OM2 branch in the setting of dyspnea on exertion. Examination was unremarkable Diagnostic workup: PET stress showed severe, large area of defect in the anterior, inferior and mid to distal lateral walls. MRI showed no viability in the LAD territory, viable LCX territory and EF 46% Management: Turned down by surgery for bypass given non-viable LAD territory. After heart team discussion, PCI of LCX/OM2 given viable LCX territory Procedure: RRA with 6F glidesheath slender, 6F EBU 3.5 guide was used to engage the LM revealing -
Left Main: No disease,
LAD: 100% occluded (proximal CTO, unchanged),
Mid-LCx: 70% lesion (treated with DES), and
OM2: Proximal 90% lesion, focal undilatable lesion Intervention: Runthrough used to wire and placed in distal OM2, followed by predilation of ostial OM2 with a 2 x 12 mm compliant balloon, residual focal waist then 3.0x8mm NC balloon at up to 22 atms but no resolution. Attention turned to mid-LCX lesion – stented with 4.0x23mm Xience Sierra. A 4.0x12mm NC was used to post-dilate the stent at high pressures. Angiogram following stent deployment showed distal OM2 wire perforation. Using 2.5 mm NC balloon, tamponade of the distal vessel was performed with residual active extravasation into the pericardium. Pericardiocentesis performed using a pericardiocentesis needle. A pigtail drain was then placed in the pericardium and autotransfusion was performed with administration of IV fluids. A Renegade microcatheter which was placed in the distal OM 2 and Vortx coils were used (2mmx5mm, 4x4mm and another 4x4mm) in the mid to distal OM. Angiogram then showed very minimal flow in the perforation.Patient was stable with minimal inotropic support
Discussion
- Risk of Coronary Perforation:High-pressure balloon inflation and wire manipulation in tortuous or resistant lesions.
- Rapid Recognition:Prompt angiographic diagnosis of perforation and extravasation.
- Effective Management: Balloon tamponade, pericardiocentesis, and embolization are critical interventions.
- Multidisciplinary Coordination: Importance of teamwork in managing complications during PCI.