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A 67-year old male, hypertensive, diabetic, came in for elective coronary angiogram. Patient is asymptomatic with normal resting echocardiogram but with abnormal stress test (>1.0 mm downsloping ST-segment depression in leads II, III, aVF, V3 to V6). He is a non-smoker, non-alcoholic beverage drinker and denies illicit drug use.Patient’s vital signs are within normal limits. He is overweight; body mass index of 27.8 kg/m2. Physical examination is unremarkable.

ECHOCARDIOGRAMNormal left ventricular geometry. Adequate wall motion and contractility. Calculated ejection fraction of 65.2 % by Simpson's method. Grade I diastolic dysfunction. Normal right ventricle. Mild tricuspid regurgitation.TREADMILL STRESS TEST (MODIFIED BRUCE PROTOCOL)Abnormal Stress Test Stage 2; METS 5More than 1.0 mm horizontal to downsloping ST segment depression in leads II, III, aVF, V3 to V6 at stage 2 to recovery 2.

The left main coronary artery has a non-significant stenosis at the distal segment.The LAD has a moderate stenosis at early proximal and severe stenosis at late proximal segments. The LCx is diffusely diseased with moderate stenosis at late proximal, severe stenosis at mid segments and moderate stenosis at proximal segment of the OM3 branch.The RCA has near total occlusion at proximal and chronic total occlusion at early mid segments. The more distal segments are seen via collateral vessels.

PCI OF LADA 7F catheter (Medtronic Launcher EBU 3.5) insertedCoronary wire (Asahi SionBlue) advancedProximal-mid segment pre-dilated with 2.5 x 15 mm balloon (OrbusNeich Sapphire II Pro)A 3.0 x 34 mm DES (Medtronic Onyx) deployed in proximal-mid segment at 14 atm (3.1 mm)Type B dissection seen at distal end of the stentA 2.75 x 12 mm DES (Medtronic Onyx) deployed in mid segment overlapping the edge of previous stent at 13 atm (2.88 mm)PCI OF RCAA 7F catheter (Medtronic Launcher JR4) insertedCoronary wire (Asahi Fielder XT-R) did not cross mid segment after several attempts; successfully crossed with another wire (Asahi Miracle 6)A 6F guide extension (Boston Scientific Guidezilla) was usedType III perforation seen at mid segmentBalloon tamponade using 2.0 x 18 mm balloon (OrbusNeich Sapphire II NC); inflated at 16 atm (2.07 mm) for 7 minutesNo leak seen afterDistal-proximal segments pre-dilated using 2.0 x 18 mm balloon (OrbusNeich Sapphire II NC)A 150 cm microcatheter (Asahi Caravel) used only to change the wire (Asahi Miracle 6) with another wire (Asahi Sion Blue) via balloon trappingFurther pre-dilatation with 2.5 x 15 mm balloon (OrbusNeich Sapphire II Pro) doneA 2.75 x 48 mm DES (Boston Scientific Synergy) deployed in mid-distal segment at 12 atm (3.01 mm)A 3.5 x 48 mm DES (Boston Scientific Synergy) deployed in proximal-mid segment at 16 atm (3.95 mm)No residual perforation or dissection

Coronary artery perforations and dissections are rare but life-threatening complication of percutaneous coronary intervention. Several risk factors increase the risk of these complications such as chronic total occlusion, old age, diabetes and long lesions. All of these are present in our patient. Immediate recognition is key to effective early management of these problems encountered during the procedure. For this case, overlapping stent in the coronary artery dissection and prolonged balloon inflation in coronary artery perforation controlled further progression. Appropriate management is life-saving.