E-Science Station

2638941

68-year-old man, non-smokerHTN, Old CVA and Hyperlipidemia with medicationsProgression of dyspnea on exertion during walking in recent 3 months, physical examination on heart revealed PMI over midline of left clavian, 5th intercostal space, regular heart beats, nosignificant murmur, no S3, no S4, no pitting edema over bilateral lower legs

ECG: Sinus rhythm, NSSTTCCXR:  Emphysema, normal heart borderCoronary CTA: 2-vessel disease with critical stenosis over LAD at p-m LAD > 90% stenosis, 30% narrowing at RCA, 40%narrowing at d-LCx, and 50% at RIEcho: LV enlargement, mild MR & TR,  preserved LVSF with EF: 65%

LMCA:    D/3: Discrete eccentric stenosis, maximum 50%LAD:     Ostium: Discrete eccentric stenosis, maximum 50%    P/3 to M/3: Diffuse eccentric stenosis, maximum 80-90% and with myocardia bridgeLCx:     M/3: CTO with collateral flow from DBRamus Intermediate :    P/3: Discrete eccentric stenosis, maximum 90%RCA: PatentJ-CTO score：1Syntax score：31
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The 7 Fr EBU 3.5 guiding catheter was used. First attempt with XTR but failure because the hard proximal CTO cap. After changing to Gaia 1st wire, we penetrated the proximal CTO cap through the lesion to the middle part, but the Gaia 1st wire was in the subintimal space. We penetrated the distal CTO cap with parallel wire technique by Gaia 2^ndwire. Following angiogram showed little contrast extravasation over the distal branch. The Gaia 2nd wire was in the false lumen. We pulled back Gaia 2nd wire a little then manipulated it to the distal true lumen. PCI with balloon and stenting was done over from the distal to proximal part of LCx. Contrast extravasation and staining with quick dissipation along small channel out of the distal branch of LCx after completing PCI to LCx. No symptoms or hemodynamic change. Echocardiography showed no pericardial effusion. Spontaneous healing was expected and following PCI with stenting over LAD and RI was proceeded. Patient had developed dizziness, cold sweating and paleness after getting up from bed at ward, about 40min after completing PCI. Cardiac tamponed and shock was confirmed and emergent pericardiocentesis was done (total 300 cc bloody pericardial effusion). Following angiography showed persistent coronary perforation at distal LCx branch with contrast staining. Good hemostasis was achieved after deploying two coils at the perforation channel at distal LCX branch. Following angiography showed no more contrast staining or extravasation.

1. Coronary perforation is the one of the challenging issues and complication during CTO PCI.2. The incidence of coronary perforation is still happened without any lowering, even the improvement of technique and devices.3. Closely hemodynamic monitoring and survey of cardiac tamponade and emergent pericardiocentesis are necessary when coronary perforation. 4. Distal wire out of lumen is one of the reasons of coronary perforation, mostly due to heavy tip load of wire.5. Balloon inflation must be done initially when perforation. Embolization with coil, thrombin, and fat maybe considered in the advanced management during distal perforation. Covered stent is also the choice.