Complication Management - Complication Management
Coronary Perforation and Aortic Stenosis: A Dangerous Combination
Mario Bollati1, Pietro Mazzarotto2
Ospedale Maggiore di Lodi, Italy1, Lodi Hospital, Italy2,
A 78 woman with diabetes and hypertension came to our attention for chest pain at rest since three hours. She had previously paroxysmal atrial fibrillation, with apixaban anticoagulation and three years before an acute coronary syndrome with NSTEMI managed medically.Morevorer, she dah a moderate aortic valve stenosis with no symptoms. echo basal.avi
EKG was unremarkable, the echocardiogram showed a normal left ventricle function, lateral wall hypokinesia and severe aortic valve stenosis. Labo showed a positive T troponin, without any other significant findings. Considering the symptoms persistence despite maximal medical management, the patent was referred for emergent coronary angiography.
The coronary angiogram showed a critical alesion of anterior descending and circumflex, with minimal atheromasia od the rigth coronary. Diffuse aortic valve calcification were also evident at "blanco" angiogram pre.avi
After stenting of anteriori descending, percutaneosu coronary angioplasty of circuflex was attempted. The guidewire was wrongly placed in small distal circumflex. After direct stenting (drug eluting stent, DES, 3.0/15), coronary injection revealed proximal perforation.3.0 balloon was immediately placed at the level of perforation Careful angiogram evaluation revealed that the guidewire was not placed in the main branch, but in a little minor vessel.
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The steps were:
Pericardial drainageAortic balloon valvuloplasty (BAV) with peak gradient from 100 mmHg to 50 mmHg, Regain the access to the main circumflex axis, now occluded by a major dissection at the perforation level, using a Pilot 150 guidewire supported by Turnpike LP microcatheter Place a covered stent (Bentley 3.0/15) towards the circumflex, sealing the perforation Seal completely the dissection with another stent implantation
Careful and complete angiogram evaluation represents a main element during PCI, both for correct stenosis evaluation both for procedural planning (stent length and calibre, contiguity of bifurcation and correct vessel course).
In case of complication like perforation and vessel closure, coronary Total Occlusion (CTO) and structural intervention techniques knowledge may represent a game changer element.
CTO and structural techniques diffusion must be encouraged, also in centres without an oriented CTO/TAVI program, due to the importance of a wealth of knowledge treating not only complex cases, but also potentially fatal complications.