Type III Coronary Perforation Rescued by 2 Covered Stents

By Muhammad Imran Abdul Hafidz
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Muhammad Imran Abdul Hafidz


Muhammad Imran Abdul Hafidz1


Pantai Hospital Kuala Lumpur, Malaysia1
Complications - Complications

Type III Coronary Perforation Rescued by 2 Covered Stents

Muhammad Imran Abdul Hafidz1

Pantai Hospital Kuala Lumpur, Malaysia1

Clinical Information

Patient initials or Identifier Number


Relevant Clinical History and Physical Exam

The patient was an 81-year-old female with a past medicalhistory of ischaemic heart disease (angioplasty to the right coronary artery in2015), type 2 diabetes mellitus and end stage renal failure on regular dialysis.She presented with several angina episodes during herdialysis sessions. Afterinitially choosing to manage the angina medically, she eventually agreed toundergo coronary angiogram.

Relevant Test Results Prior to Catheterization

Relevant Catheterization Findings

Interventional Management

Procedural Step

 Cardiac catheterisation would be done via theleft radial route. A 6 Fr Terumo radial sheath was used. A Tig catheter wasused for the diagnostic angiogram .An EBU 3.5 Launcher guide catheter (Medtronic) was used toengage. A Runthrough NS floppy wire (Terumo) was used down the left anteriordescending artery. A Helix 2.5 x 15 mm semi-compliant balloon (cNovate Medical)was used to predilate the distal lesion initially. It was also used to predilatethe proximal lesion. As there was recoil in the distal lesion, predilation wasrepeated. Immediately a Type III perforation at the distal site was noted.Prolonged balloon inflation did not remedy the situation, hence a PK Papyrus2.5 x 20 mm covered stent (Biotronik) was used. Patient continued to destabilisewith failure to seal the perforation with the covered stent and developedcardiac tamponade. Emergency pericardiocentesis was done. A second Papyrus 3.0x 20 mm was delivered distal to the first covered stent using a Guidezilla IIextension catheter (Boston Scientific). The perforation was sealed. The left main stem and proximal left anterior descending artery lesions were treated with overlapping stents. Distally we used a 3.0 x 48 mm stent (Micro Science Medical AG) and proximally  4.0 x 13 mm stent (Micro Science Medical AG). Postdilation was done with a Vecchio 4.5 x 15 mm non-compliant balloon (cNovate Medical).

Case Summary

Coronary perforations are a feared complication of percutaneous coronary intervention. They are increased in calcified vessels, complex angioplasty and elderly patients. USing prolonged balloon inflations may work but sometimes the usage of covered stents may be required.