Abstract
Coronary artery bypass graft perforation during percutaneous coronary intervention is a rare complication. Perforation of a left internal mammary artery (LIMA) graft due to a guide catheter extension system has not been described. We report the successful deployment of a polytetrafluoroethylene (PTFE)-covered stent to seal the LIMA graft perforation due to the guide catheter extension system. Percutaneous coronary intervention was performed for a culprit lesion of the distal left circumflex via the LIMA graft. A balloon catheter failed to be delivered because the LIMA graft was very long and tortuous. The guide catheter extension system was introduced, and the balloon was delivered and inflated. However, the LIMA graft perforation with continuous extravasation was caused by the edge of deeper intubated guide extension catheter when a coronary stent was attempted to be delivered to the culprit lesion. A long balloon inflation was performed, but the perforation was not completely sealed. The PTFE-covered stent was successfully deployed and sealed the LIMA graft perforation. This case describes that the rapid deployment of PTFE-covered stent is effective to treat severe coronary artery bypass graft perforation due to the guide catheter extension system.
Highlights
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Left internal mammary artery (LIMA) graft perforation is a rare complication.
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Guide catheter extension system is useful in the complex coronary intervention.
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Intubation of the guide extension catheter portends the risk of the vessel injury.
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LIMA graft perforation was caused by the edge of the guide extension catheter.
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Polytetrafluoroethylene-covered stent was effective to treat the graft perforation.
A 62-year-old man with a history of hypertension, diabetes mellitus and dyslipidemia was admitted to our department diagnosed unstable angina because of chest pain on exercise. He had undergone three-vessel coronary artery bypass graft surgery using the left internal mammary artery (LIMA) graft and saphenous vein graft (SVG) twelve years ago.
Coronary and graft angiography were performed. Coronary angiography revealed chronic total occlusion in the mid segment of left anterior descending artery (LAD), the mid segment of left circumflex artery (LCX) and the proximal segment of right coronary artery (RCA). Graft angiography described that SVG to the distal RCA was patent. The LIMA graft to the mid LAD and LCX was patent ( Fig. 1 ). However, there was a new and severe stenosis in the distal segment of native LCX via very tortuous anatomy ( Fig. 2 ).
We decided to perform percutaneous coronary intervention (PCI) for a culprit lesion of the distal native LCX via the LIMA graft. Aspirin 325 mg and clopidogrel 600 mg were added as an anticoaglant medical treatment before PCI. After administration of 7000 units of intravenous heparin, a 6 french IM guide catheter (Boston Scientific, Marlborough, MA) from the right femoral artery was placed in the ostium of the LIMA graft. A 0.014 in. Runthrough NS guide wire (Terumo, Tokyo, Japan) was advanced through the LIMA graft and positioned in the distal native LCX necessitating balloon support for delivery. A 2.5 mm TREK balloon catheter (Abbot Vascular, Santa Clara, CA) could not be passed because of the tortuous LIMA graft. A decision was made to use the GuideLiner catheter (Vascular Solutions, Minneapolis, MN) that was a novel rapid exchange guide catheter extension system. The GuideLiner catheter was placed in the proximal LIMA graft through the guide catheter ( Fig. 3 A, B ). Second wire, a 0.014 in. WHISPER guide wire (Abbot Vascular) was advanced as a support guide wire. Predilatation of the culprit lesion was performed using a 1.5 mm Euphora balloon catheter (Medtronic, Minneapolis, MN) at 14 atm and then the 2.5 mm TREK balloon catheter was delivered and inflated at 8 atm. Following predilatation, A 8 mm Resolute Integrity stent (Medtronic) premounted on a 2.25 mm balloon catheter was attempted to deliver the distal native LCX. However, the stent could not be passed at the lesion site.
