Author + information
- Ya-Ling Yang1
Patient initials or identifier number
Relevant clinical history and physical exam
The 82-year-old man had type 2 diabetes mellitus and hypertension. He was admitted for peripheral arterial occlusive disease with the presentation of dry gangrene at right 1st toes and left 5th toe. However, non-ST-segment elevation myocardial infarction combined with acute respiratory failure was developed during the hospital course.
Relevant test results prior to catheterization
CK peak: 668 U/L
Troponin I peak: 31.47 ng/ml
Bedside heart echo: LVEF: 40% with global hypokinesia
Relevant catheterization findings
LM and triple vessel disease (LM: -ostium: 50% stenosis, LAD: -P:80% stenosis,
- M: Segmental stenosis up to 60% stenosis,
- D: Up to 90% stenosis, LCX: nondominat,
- P to -M: 50% stenosis, -OM1:up to 50% stenosis,
- OM2: 60% stenosis, -D:90% stenosis,
RCA: Dominant, -M 70% stenosis,
- D: Segmental stenosis up to 40% stenosis,
- PL: Diffuse lesion up to 90% stenosis, -PDA: luminal irregularity
A guide (XB 3.5 7F) and a floppy wire were used. LAD lesions were pre-dilated with a 3.0/15 mm Ryujin balloon catheter and subsequently stented with a 3.0/30 mm BMS (at middle LAD) and a 3.5/15 mm BMS (at proximal LAD). However, Ellis type II coronary perforation at middle LAD occurred after post-dilation. Prolonged balloon inflation with a 3.0/15 mm Ryujin balloon catheter was tried to seal the perforation. However, the bleeding was unable to stop by prolonged balloon inflation. We then removed the balloon catheter and soon delivered a 3.0/16 mm covered stent to the perforation site but failed. Unfortunately, the covered stent dislodgement occurred while we withdrew the covered stent. Immediate pericardiocentesis was performed. The whole system was then removed and an 8Fr Judkins left guiding catheter was used to engage left main coronary artery. A choice PT guidewire and a 3.0 mm balloon catheter were used for prolonged balloon inflation again and simultaneously a 0.014 whisper wire was managed to get through the dislodged covered stent successfully. A Goose Neck snare was used for covered stent retrieval but it failed. We then used small balloon technique with a 1.25/10 mm Ryujin balloon catheter advanced through the dislodged covered stent. After inflating the balloon distal to the stent, we withdrew the balloon together with the covered stent. Fortunately, followed angiography showed coronary perforation was sealed after prolonged balloon inflation.
Prolonged balloon inflation with pericardiocentesis is the mainstay of therapy for coronary perforation. Covered stents also can effectively seal coronary perforation. However, covered stent dislodgement can occur because they are bulky with limited flexibility and thus may not be easy to deliver in difficult anatomy. Fortunately, the large profile design of the covered stent also makes it possible to get through an undeployed covered stent by a coronary wire. In our case, an 8 French large guiding catheter allowed us simultaneously to manage the coronary perforation by prolonged balloon inflation and covered stent dislodgement by either snare technique successfully.