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Coronary perforation is a potentially fatal complication during percutaneous coronary intervention. Reports have shown that it occurs in 0.2 to 0.6% of all patients undergoing the procedures. Although the frequency of coronary perforation is low, it is a serious and potentially life-threatening situation that warrants prompt recognition and management. Here we present a case of distal coronary perforation, and review the management of coronary perforation in the current practice.
Coronary artery perforation is a rare, but life-threatening complication of percutaneous coronary intervention (PCI). Although microperforations are well described and well-tolerated phenomena during PCI and do not need special assistance, in cases of significant leaks (Grade III) perforation, there is almost 10% risk of complications including death.[1,2,3,4]
Coronary perforation may occur due to distal migration of guidewire with or without wire fracture. Hydrophilic-coated guidewires have an increased risk of perforation due to their low coefficient of friction and ease of distal migration.
We report a complicated case of distal left anterior descending (LAD) perforation with hydrophilic wire, which was successfully treated with fat embolization.
A 61-year-old diabetic and smoker male was admitted for elective PCI to LAD for worsening angina symptoms. He had tight LAD lesion [Figure 1].
Using right radial approach, the LAD was wired using whisper MS wire. The lesions in mid and proximal segments were predilated with a 2.5 × 12 semi-compliant balloon and stented using XIENCE drug-eluting stent 2.75 mm × 23 mm and 3.5 mm × 28 mm were deployed in mid and proximal LAD, respectively, at nominal pressures. The stents were then postdilated with 3.0 and 3.5 noncompliant balloon respective at high pressures achieving excellent results [Figure 2].
While taking final acquisitions, distal wire was noted to be in pericardial space and distal LAD perforation was noted [Figure 3]. The patient was asymptomatic and hemodynamically stable before sudden pulseless electrical activity/arrest, needing one cycle of Cardiopulmonary resuscitation. An emergency echo confirmed features of pericardial effusion and features of tamponade. Under echo and fluoro guidance, an emergency pericardial drain was inserted and 400 ml of blood was drained. The LAD wire was retrieved and placed in distal segment. To stop antegrade pericardial leak, a 2 mm × 15 mm semi-compliant balloon was inflated in distal segment for 10 min. The activated clotting time (ACT) at this stage was <200 repeated twice.
Because of distal perforation of small caliber segment, we decided to perform fat embolization. A 6 French compatible Export aspiration thrombectomy catheter was placed in the mid-distal LAD [Figure 4]. Fat was retrieved from a small groin incision and mixed it with saline and blood. This “fatty solution” was then injected through the aspiration catheter followed by 10–15 ml saline flush. The aspiration catheter was then removed. Subsequent acquisitions demonstrated complete sealing of the perforation and occlusion distal LAD [Figure 5]. Patient shifted to cardiac intensive care where several repeat echo examinations excluded pericardial fluid reaccumulation. The pericardial drained <10 ml while on free drainage for next 24 h before removal. The patient was discharged home 2 days later with cardiac outpatient follow-up appointment.
Historically, the trend for PCI is ever increasing all over the world. With increasing practice, new equipment is being developed. One of the commonly used devices is coronary guidewires with hydrophilic coating. These are particularly useful in negotiating complex, calcific and significantly tight lesion due to their ability to “slip through.” However, these wires have the tendency to flow into smaller branches and sometimes through the arterial wall leading to a perforation.
The Heart Hospital is a large tertiary surgical center which performs over 2500 PCIs yearly. The organization has a particular commitment to teaching, innovation, and adapting new technologies. Not surprisingly, therefore, a range of hydrophilic wires is used commonly, yet coronary perforation is a very rare PCI complication at our center.
Using this case report as a background, we shall discuss briefly how to minimize the risk of perforation and how to treat it.
There are a number of precautions to be taken which may reduce risk of coronary complication:
Identifying, treating, and following up are the mainstay of this section.
In most of the cases of acute pericardial blood accumulations, patients will have chest pain or suddenly arrests. It is important to consider perforation as strong possibility in such cases, urgent echo would exclude/confirm pericardial collection.
What should we treat the perforation first or the tamponade?. If the patient is hemodynamically stable, it is wise to seal the perforation antegradely before treating tamponade. On the other hand, if the patient has arrested or showing signs of impending arrest, treat the tamponade first before further coronary work [Chart 1], use of fluoroscopy along with the echo improves correct drainage.
While a number of algorithms have been described in the literature, we suggest a rather simplified “two-questions” approach, as detailed in the following Chart 1. Because reaccumulation is not uncommon as perforation could be from multiple sites simultaneously, repeat echo in the first 24–48 h are, therefore, extremely important and the patients should be followed up closely as they tend to develop pericarditis later.
Coronary perforation is a devastating complication and can be fatal if not treated promptly and effectively. It is crucial that all interventionalists should have a clear and robust understanding of coronary perforation to minimize the risk, identify, and manage it appropriately.
There are no conflicts of interest.