Abstract
Covered stents are indicated for coronary perforations, but they may seal off major side branches in that process. We report the successful sealing of an ostial left main perforation, induced by a guide catheter in the course of a retrograde approach to treat a chronic total occlusion (CTO) of the right coronary artery (RCA) in a 76 year old woman with prior CABG. The implanted Papyrus covered stent, however, overlapped the left main bifurcation and occluded the non-grafted circumflex artery (CX) resulting in acute ischemia. Through a double lumen catheter advanced over the wire located in the left anterior descending coronary artery (LAD) territory, a stiff recanalization wire could be advanced from the side-port to penetrate the stent membrane towards the CX. This was successfully achieved, and after subsequent dilatation, a drug-eluting stent was implanted in Culotte-fashion from the CX to the left main with subsequent kissing-balloon dilatation. The clinical symptoms subsided immediately, and the RCA was finally recanalized in antegrade parallel wire technique. No periprocedural infarct was observed during 48 h of follow-up before discharge. At clinical follow-up of 6 months the patient is symptom-free.
1
Introduction
A perforation of a coronary artery is one of the most dreaded complications of coronary intervention. The perforation type is classified according to Ellis , and they occur in about 0.1–3.0% of interventions , with type III being the most lethal. A recent review focusing on Ellis grade III perforations, which represents the type observed in our present case, shows an incidence of 0.2% with a mortality of 45% . The presence of complex lesions, specifically CTO, is one of the predictors of these perforations. The treatment options are prolonged balloon inflation, and pericardiocentesis when needed, coil embolization in case of distal perforations, and the use of covered stents . Covered stents are a major advance in the interventional treatment of coronary perforations .
1.1
Case report
A 76-year-old woman (149 cm height, 59 kg weight) had undergone coronary artery bypass surgery (CABG) in 1995 with a left internal mammary artery (LIMA) graft to the left anterior descending artery (LAD), and a venous graft to an occluded right coronary artery (RCA) at that time. She presented to her cardiologist with functional class 3 symptoms and severe dyspnea and underwent a diagnostic coronary angiography. The angiography showed a subtotal occlusion of the mid segment of the native LAD in the with a patent LIMA graft supplying the distal LAD. The left circumflex coronary artery (CX) was not diseased and the RCA was totally occluded ( Fig. 1 ), and was supplied by collaterals from the LAD. Viability was present in the hypokinetic territory of the codominant RCA. The J-CTO score was 2 (>20 mm and calcified). As further comorbidity there was chronic kidney disease (CKD) with a serum creatinine of 1.6 mg/dl and a calculated creatinine clearance of 26 ml/min.
The treatment strategy was to recanalize the RCA CTO using the retrograde approach via the native LAD after establishing patency to mid LAD (functional LAD occlusion; Fig. 1 ) in order to limit the contrast use to 120 cm 3 .
2
Procedure
Bilateral femoral artery access was obtained using 7F sheaths. A 7F AL-1 guide with side holes [Launcher® catheter; Medtronic, Washington, DC, USA] was advanced into the RCA ostium, and a 7F EBU 3.5 with side holes [Launcher® catheter; Medtronic, Washington DC, USA] was put into the left main coronary artery (LM). A Runthrough floppy wire [Terumo Medical Corporation; Somerset, NJ, USA] was placed in the distal diagonal beyond the subtotal occlusion of the LAD, but the LAD itself could not be reached ( Fig. 2 A ). Therefore, balloon dilatation was attempted to enable access to the LAD, however none of the low-profile balloons Tazuna 1.25 mm [Terumo Medical Corporation; Somerset, NJ, USA] or a Sapphire Pro [Orbus Neich, Fort Lauderdale, FL, USA] would cross despite forceful guide catheter back-up.
During these attempts, the patient suddenly complained of severe chest pain, and developed hypotension. Immediate angiography of the LM showed an ostial perforation of Ellis grade III into the aortic wall ( Fig. 2 B). Vasopressor agents were given to stabilize the blood pressure, and a Papyrus PK covered stent [Biotronik, Lake Oswego, OR, USA] of the shortest available length of 3.5 × 20 mm was placed at the ostium of the LM. Angiography showed no further extravasation of the dye; however, the patient continued to have severe chest pain and now developed ST segment elevation in the inferior leads. The angiogram showed that both the CX and the intermediate branch were now occluded by the covered stent, which extended across the ostium of the CX ( Fig. 2 C). No collateral filling of the CX was observed neither from the LAD, nor from the LIMA graft (which was quickly visualized with a diagnostic catheter using the second femoral access).
To rescue this distal LM bifurcation obstruction, a FineDuo dual lumen catheter [Terumo Medical Corporation; Somerset, NJ, USA] was advanced over the Runthrough that was still placed in the diagonal branch. Through the distal over-the-wire side port, a Confianza Pro 12 [ASAHI Intecc, Santa Clara, CA, USA] was advanced to probe the covered stent towards the direction of the CX based on the available reference images in two planes. The wire passed relatively easily through the polyurethane cover of the stent and could be smoothly advanced distal. As there was no collateral filling, the tactile feedback was the only indicator of a true lumen passage ( Fig. 2 D). After removal of the Crusade catheter using the trapping technique, a 1.25 Tazuna balloon [Terumo Medical Corporation; Somerset, NJ, USA] was advanced and dilated. This provided immediate antegrade flow. After subsequent dilatation with a 2.5 mm balloon the flow was completely restored into the CX and the intermediate branch, and symptoms subsided immediately. To ensure the durability of this fenestration of the Papyrus stent, a Promus 3 × 12 mm was positioned across the ostium of the CX to the LM, and then a proximal optimization of the stent in the distal bifurcation was done using a 3.5 × 6 mm NC balloon (Accuforce®; Terumo Medical Corporation; Somerset, NJ, USA]. Recrossing into the LAD was achieved with a Pilot 50 wire [Abbott Vascular, Santa Clara, CA, USA], and a final kissing balloon dilatation was done with 3.0 balloons in both LAD and CX ( Fig. 2 E) with excellent angiographic flow ( Fig. 2 F).
At that time with complete symptom relief size and hemodynamic stability, with a procedure time of 90 min, the patient consented to proceed with the antegrade attempt to recanalize the RCA via the antegrade route. We changed to an AL 0.75 guide, and used the LIMA via a diagnostic 4F catheter for contralateral imaging of the distal RCA ( Fig. 3 A ). A Gaia 2 wire [ASAHI Intecc, Santa Clara, California, USA] was advanced on a Finecross microcatheter [Terumo Medical Corporation; Somerset, NJ, USA] into the proximal RCA, when after penetrating the proximal cap it went subintimal. After removal of the Finecross, a second stiffer wire (Confianza Pro 12) was advanced in parallel fashion on the Finecross along the first wire to achieve rapid access to the distal cap with successful intraluminal position within 3 min of procedure time ( Fig. 3 B). Then after ballooning, two drug-eluting stents [Ultimaster®; Terumo Medical Corporation; Somerset, NJ, USA] of 3.5 × 28 mm dimension were implanted with TIMI 3 flow and no residual stenosis ( Fig. 3 C). The stent sizing and positioning were done with intravascular ultrasound [Eagle Eye Platinum; Volcano, San Diego, CA, USA] to avoid further contrast use.
