Abstract
Coronary artery perforation is a rare however potentially life-threatening complication of percutaneous coronary intervention that could cause cardiac tamponade. It requires emergent surgery unless an appropriate procedure is performed immediately. In distal coronary artery perforations with guidewires, several procedures were reported to be effective in refractory cases after prolonged balloon inflation and reversal of heparin by protamine sulfate to induce hemostasis. We describe a case of successful collapse distal coronary artery treatment with a syringe for thrombus-aspiration without materials for an embolization after guidewire-induced coronary artery perforation.
1
Introduction
Increasing “challenging cases” of percutaneous coronary intervention (PCI), such as cases of chronic total occlusion (CTO), are performed since indication for PCI was extended further on drug-eluting stent (DES) era. Coronary artery perforation is a rare (0.17–2.8% of total cases) potentially life-threatening complication which may cause cardiac tamponade during PCI. It requires emergent surgery unless an appropriate procedure is accomplished immediately.
Of the coronary artery perforations, 36% were induced by guidewires . In distal coronary artery perforations with wires, several hemostasis procedures were reported to be effective in refractory cases after prolonged balloon inflation and reversal of heparin by protamine sulfate . These procedures selectively deliver microcoils, Gelfoam, and subcutaneous tissues into perforated distal coronary arteries as an embolization .
This report describes a successful case of collapse distal coronary artery treatment with a syringe for thrombus-aspiration without materials for an embolization after guidewire-induced coronary artery perforation.
2
A Case report
A 67-year-old male was referred to the cardiovascular division for angina pectoris of Canadian Cardiovascular Society angina grade II and low blood pressure when hemodialysis was performed. Transthoracic echocardiography indicated normal systolic function on the patient. The patient’s coronary angiography (CAG) revealed significant proximal and distal stenoses of right coronary artery (RCA), left anterior descending artery (LAD), and a chronic total occlusion (CTO) of mid left cicumflex artery (LCx; Fig. 1 A). PCI was performed for RCA and LAD. Both lesions were treated successfully with four DES (Cypher, Johnson & Johnson). Aspirin (100 mg/day) and clopidogrel (75 mg/day) were prescribed as antiplatelet regimens.
PCI was performed for CTO of mid LCx on a following hospital visit, and 5000 U of heparin was administered; 8F AL 2.0 (Launcher, Medtronic) was used as the guiding catheter. A 0.014-in. hydrophilic coated with polymer sleeve guidewire (Fielder FC, Asahi Intecc, Japan) was advanced into CTO lesion with a micro-catheter (Carnelian Pixie, 1.8F/2.7F 135cm, Tokai Medical Products, Japan). The guidewire was passed through CTO lesion with ease than expected, then CTO lesion was dilated in a consecutive order with 1.25/10 mm (Ryujin Plus, Terumo, Japan), 2.0/12 mm (Voyager, Abbott) and 2.5/15 mm balloons (Sprinter, Medtronic). After the third balloon inflation, CAG revealed extravasation from the distal side of LCx due to coronary artery perforation with the tip of guidewire ( Fig. 1 B). We immediately exchanged the wire for a 0.014-in. nonstiff guidewire (Rinato, Asahi Intecc) and attempted hemostasis with prolonged balloon inflation with a 2.5/15 mm balloon (Sprinter, Medtronic) and reversal of heparin by protamine sulfate. As a result, the active clotting time was reduced from 248 to 152 s. Although the balloon inflation was prolonged for two additional 30-min cycles, the leakage remained. Fortunately, a systemic circulation remained stable, and echocardiography revealed a little pericardial effusion. Pericardiocentesis was judged risky rather than unnecessary at this stage.
The microcatheter (Carnelian Pixie) which had been withdrawn from coronary artery was inserted again into the perforated side of LCx, collapsing vessel with a syringe to break down a fatal situation. The syringe for thrombus-aspiration (Eliminate, 5.3F/4.2F 140 cm, Clinical Supply, Japan; Fig. 2 ) was attached to the end of microcatheter while applying negative pressure to absorb blood on the distal side of LCx. Blood aspirated into the syringe was little, indicating the presence of a completely collapsed vessel. CAG also revealed occlusion with no evidence of contrast medium beyond the tip of microcatheter.
