Coronary perforation during pci Case presentation

1. Complex Cases in Interventional
Cardiology

2. Dr Name : Anup Ashok Pusate
Place : Nagpur
Hospital name : Suretech Hospital
Topic: Right Coronary artery & Ventricle
Perforation

3. CASE BRIEF
67yr, Male
Rest angina since 12 hrs
Heart rate – 60/min
BP- 140/90mmHg
Systemic examination- NAD
ECG- Acute IWMI
Diagnosis- Acute IWMI, DM HTN LVEF 40%

4. • CAG- 80% stenosis in mid segment of RCA
• Patient was taken for PCI to RCA
• Inj heparin, ticagrelor, aspirin, rosuvastatin, pantoprazole were given
• DES 3 x 44mm stent was inflated at 12 atm
• Post balloon- stent inflation- NC 3.5 x 15 @ 20 atm
• After balloon dilatation an Ellis type III coronary perforation occured
at stented segment
• Hypotension and cardiac tamponade occurred immediately.

5. • Prolonged balloon inflation @ 6 atm with 3.5x 15 mm semicompliant
balloon done which sealed the perforation.
• 11cm long, 6 Fr, introducer catheter sheath was introduced
percutaneosly through substernal space for pericardiocentesis but it
perforated RV and went into pulmonary artery.
• So another 6fr, 11cm sheath was introduced into pericardial space
through substernal space and a 6 fr pigtail was introduced through it
into pericardial space and pericardiocentesis was done.
• 1st sheath was removed after 1 hour. 2nd sheath and pigtail removed
after 48 hrs
• After 3 days patient was discharged.

6. Intervention Technique name
Prolonged Balloon inflation and pericardiocentesis

7. Complexity / Innovations Intervention Technique name
Coronary perforation although rare can occur at anytime during PCI.
Incidence is 0.43% with PCI.
The risk of CAP is associated older patients, complex coronary anatomy,
calcification, use of oversized balloons or stents, excessive
postdilatation, and use of atheroablative devices and hydrophilic
guidewires.
The imminent lethal outcome of CAP stems from the hemodynamic
compromise of ensuing cardiac tamponade.
Treatment is conservative (including prolonged balloon inflation) in
73.3%. Covered stents, coiling, and fat embolization can be used if
required.
Pericardiocentesis for tamponade can be required in 48.0%.

8. Diagram/Photograph/ Videos
Before Intervention After Intervention
You can attach photograph(s) of the case with Case Synopsis

10. Lesson learnt from the case
Always confirm about position of sheath in pericardium.
Dye can be injected into sheath if position is doubtful.
Always introduce second sheath into pericardial space before removing
1st sheath if it perforates ventricle.
CVTS should be in active mode.

11. • Thank you