MR HT

Mr HT, 71 years old, gentleman with  Underlying Hypertension, Hyperlipidemia, Chronic Kidney disease (stage 3). He complain of intermittent atypical chest pain, otherwise no other symptoms. His clinical examination were unremarkable. He had exercise stress test, which was positive at stage 3 (new onset LBBB). He was then referred to our center for coronary angiogram. 
Echocardiography done prior to angiogram showed normal LVEF with no regional wall motion abnormality. All valves normal

Approach: Right Radial 6FCatheter: Optitorque LMS: normalLAD: CTO distal RCA, collateral from right RCALCx: mild disease OMRCA: diffused mild disease
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Strategy was made to use antegrade wire escalation as initial approach. An EBU 6Fr guiding catheter was utilized, which was seated well within ostium of left main stem. Microcatheter Caravel was utilized with initial Fielder XT wire. The wire managed to reach the proximal cap easily. However further advancement of wire was futile as the wire tend to enter side branches.Guidewire escalation to Gaia 2nd done. Subintimal wiring eventually leads to Ellis type III perforation. An uncommon method was used to prevent further blood flow into the pericardium by using the Caravel microcatheter. The device distal end was seated near the proximal CTO cap, in which due to diffuse disease of the vessel allows the microcatheter to occupy fully the vessel lumen and prevent further antegrade blood flow. Furthermore, despite the perforation being located in the mid LAD, the unique anatomy makes the situation behave like a distal wire perforation.Usual preparations are carried out in dealing with coronary perforation - Echo, surgeon standby. We quickly move to secure hemostasis by exchanging to Rapid Transit microcatheter and carried out fat embolization. 2 attempts in delivering fat tissue were successful in sealing perforation site. Hemodynamics remain stable throughout with final repeated Echo showing minimal pericardial effusion. Upon removal of guiding catheter, heparin reversal was given with Protamine.
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This case demonstrates fat embolization in mid vessel perforation which behaves like a distal wire perforation. Early recognization and action play an important role. In dealing with perforation, the operators must be aware of methods of achieving hemostasis which may differ from the standard guideline approach. Particularly, in this case, microcatheter was used as a method to achieve hemostasis.