YS

Female, 64 years old, has chief complaint of easily fatigue during moderate activity. She had history of Inferior STEMI four months prior to recent admission, underwent primary PCI in RCA with 3VD. CAD risk factors: Hypertension and Dyslipidemia. Blood pressure 170/75 mmHg, heart rate 58 bpm, oxygen saturation 99% room air. 

ECG showed inferior Q waves with inverted T waves at anterolateral and inferior. Echo revealed EF 37% with preserve RV function, abnormal LV diastolic function (grade I) with normal LA pressure, akinetic wall motion at basal to mid anterolateral and inferolateral, hypokinetic at basal to mid anterior, anteroseptal and inferoseptal. Dobutamine Stress Echo (DSE) was performed and there was biphasic phenomenon at basal to mid anterior segment, confirming viability of LAD teritory.

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PCI was performed from femoral access due to planned rotational atherectomy (RA). Angiography revealed right common iliac tortuosity, and coronary angiography showed normal LM, heavy calcification with 80-90% stenosis at LAD mid part, and 90% stenosis at LCx right before OM1 branch. 
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We did femoral access PCI but encountered difficulty when canulating LCA, so we changed into long femoral sheath (7F, 25 cm) but still didn't pass through the tortuossegment, so we changed to longer femoral sheath (7F, 60 cm). We performed rotational atherectomy with 1.75 burr size followed by predilation with NC scoring balloon2.5x20 mm (20 atm) at proximal to mid LAD. Stenting was done with DES 3.5x24 mm at mid part dan DES 3.5x28 mm at proximal part with good result. Patient was hemodinamically stable during procedure with no significant symptom. During observation at the recovery room, patient complained abdominal discomfort, looked pale and diaphoretic. Blood pressure dropped to 70/50 mmHg, fluid resuscitation was done with additional vasopressor. Echo was performed but with unremarkable result. Abdominal USG showed free fluid at perivesica and hepatorenal recess indicating retroperitoneal haemorrhage. Patient was sent to cathlab immediately to performed angiography and revealed there was perforation at right common iliac artery. Balloon tamponade was done with Mustang balloon 6.0x60 mm at proximal tear, followed by implantation of S&G Biotech INC bifurcated stent graft 10x40 mm. Angiography evaluation showed good result without residual perforation. Haemoglobin dropped to 9.4 from 13, PRC tranfusion was given. Patient continuously improved and get discharged after 5 days.
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Retroperitoneal haemorrhage is rare yet disastrous complication that need prompt treatment to prevent further deterioration. In dealing with tortuosity, we need additional tools (e.g long sheath, stiff guidewire or even vascular cover stent or surgical backup in case of complication) to avoid complication.