Author + information
- Shingo Hosogi1
Patient initials or identifier number
Relevant clinical history and physical exam
A 87 years old female. She transferred to our hospital for the TVAR to abdominal aortic aneurysm (maximum diameter 76 mm).
ECG and TTE were almost normal.
CAG before TVAR showed LAD#7 CTO, Careful medical interview revealed chest discomfort on effort several years ago. Thus, we planned PCI for LAD#7 CTO. Coronary Risk Factors: HT, Dyslipidemia.
Relevant test results prior to catheterization.
Relevant catheterization findings
1. Short CTO lesion in LAD#7
2. Calcification in CTO segment
3. Collateral vessel from LCX#1
1. XTR guide wire (GW) with micro-catheter (MC)was successfully crossed the CTO lesion.
2. CTO lesion was dilated by small balloons with severe indentation due to severe calcification, so was ablated by rotablator of 1.25 mm burr.
3. Small 3rd diagonal branch (Dg) was protected by Run through Ultra floppy (RTU) GW and dilated by 1.5 mm balloon.
4. CTO lesion was dilated 2.25 mm scoring balloon and deployed DES up to 10 atm with mild indentation at the proximal stent part from the 3rd Dg.
5. The RTU was entrapped between calcification and stent, and could not be removed by using MCs and small balloons with anchor balloon at distal stent part.
6. Under-extended stent part was dilated by 2.75 mm scoring balloon, then blood pressure suddenly fell down to 50 mmHg.
7. CAG revealed coronary rupture and TTE revealed moderate pericardial effusion.
8. Vital state was stabilized by 3.0 mm balloon inflation at hemorrhagic part and pericardio centesis and noradrenalin drip infusion, however, the entrapped GW could not move at all.
9. Rotablator was tried to cut the RTU in coronary artery, but resulted in failure.
10. After ablation around the proximal part of the stent, entrapped RTU could be fortunately removed.
11. Covered stent was deployed and completely sealed at the ruptured part.
12. 2nd DES implantation and kissing balloon inflation were performed at proximal stenosis of the 1st stent across 2nd Dg.
13. Final CAG showed good dilatation and TIMI 3 flow and complete hemostasis.
We experienced a case of coronary rupture during treatment of entrapped GW between calcification and stent in the PCI for CTO lesion. In the common PCI, some 1st line guide wires have mild hydrophilic coating for avoiding wire perforation. However, we should know that these GW may have the risk for the entrapment between calcification and stent.