Akademik Veri Yönetim Sistemi
TSC ISTANBUL CTO AND CHIP MEETING, İstanbul, Türkiye, 25 - 28 Eylül 2025, ss.1-5, (Özet Bildiri)
Emergent Surgical Revascularization for Left Anterior Descending Artery
Perforation During Chronic Total Occlusion Percutaneous Coronary Intervention: Successful
Bailout with Coronary Artery Bypass Graft
Introduction
Coronary perforation (CP) is a rare but
emergent complication of percutaneous coronary intervention (PCI), requiring
immediate diagnosis and management. Reported series indicate an incidence
ranging from 0.40 % to 0.71 % 1–3. Even with prompt recognition and treatment, it is associated with
high mortality rates, myocardial infarction (MI), and an elevated need for
target vessel revascularization (TVR). Cardiac tamponade and hemodynamic
collapse following perforation are the primary causes of mortality 4. In this case, during PCI for left anterior descending artery (LAD) chronic
total occlusion (CTO), CP occurred, precipitating cardiac tamponade. Pericardiocentesis
was performed, followed by prolonged balloon inflation proximal to the perforation
site and the patient was referred to emergency surgery.
Case Report
A 63-year-old male with hypertension and type
2 diabetes presented to our clinic after declining surgical revascularization.
One week earlier, he underwent primary PCI for an inferior STEMI (right
coronary artery (RCA) culprit), with subsequent angiography revealing
multivessel disease: an 80% mid-segment stenosis in the circumflex (CX) artery
and proximal CTO of the LAD artery with grade 2 collateral filling (Fiig. 1A
and 1B). The lesion complexity was underscored by a J-CTO score of 3
(calcification, blunt stump, length >20 mm). Given the patient’s preference
and angiographic findings, CTO-PCI of the LAD was planned. A 7-French sheath
was inserted via the right femoral artery. The left main coronary artery (LMCA)
ostium was cannulated with a 6-French EBU guiding catheter, while the RCA
ostium was engaged using a 6-French JR diagnostic catheter. A 0.014-inch floppy
guidewire advanced through a microcatheter to the mid LAD but failed to cross
the lesion distally. Wire escalation was attempted: initial workhorse floppy
wire was exchanged for a Gaia Third wire (Asahi Intecc), followed by a Conquest
Pro 12 guidewire (Asahi Intecc) after unsuccessful capsular penetration. The
Conquest Pro 12 wire progressed subintimally; upon recognition, retrieval was
attempted, but the microcatheter became trapped within mid-LAD calcification. Post-procedural
control diagnostic angiography showed a Ellis class 3 coronary perforation in
mid-LAD (Fig. 1C). Echocardiography confirmed severe pericardial effusion with
rapid progression to hemodynamic collapse and hemodynamic instability due to
cardiac tamponade. Emergent pericardiocentesis was performed. A 3.0×15 mm
balloon (Shunmei) was inflated to 6 atm at the perforation site (Fig. 1D).
Since hemodynamic instability continued the patient was transferred to surgery
after consultation with the cardiothoracic surgery team. Intraoperatively, the
balloon was deflated and removed. The patient underwent LAD-left internal
mammary artery (LIMA) and sequential saphenous vein grafts to OM1/OM2 (Fig. 2A
and 2B). After 2 weeks of hospitalization, echocardiography showed no
pericardial effusion, preserved LVEF (50%), and mild mitral regurgitation. The
patient was discharged with optimal medical therapy.
Discussion
CP, a rare but serious complication of PCI,
can be life-threatening and is associated with patient-related factors, lesion
characteristics, and procedural complexity. Diabetes, hypertension, chronic
renal failure, advanced age, female gender, history of CABG are risk factors
for coronary perforation. Also CP significantly increased in the setting of
complex lesions, including CTO, heavy calcification, coronary tortuosity,
complex and type C lesions, longer lesions (>10 mm), eccentric plaques and
small vessel diameter 5. The perforation rate is particularly high in CTO procedures and has
been reported as 8.9% and 4.9% in different series 4,6. Operators should be careful
for CP when using large balloons, stents, atheroablative devices or hydrophilic
guidewires, especially in high-risk patients. The management strategy depends
on factors such as perforation site and severity, the patient's hemodynamic
status and available equipment in the catheterization laboratory. In small
vessel perforations, hemodynamic support, reversal of heparin anticoagulation,
prolonged balloon inflation, pericardiocentesis or coil embolization of the
perforated vessel may suffice. In contrast, larger vessel perforations
typically require covered stent deployment or emergency surgical intervention 7,8. Covered stents play a critical role in managing proximal perforations.
Often excessive balloon dilatation and large size stent selection cause
proximal CP. Covered stents can rapidly and effectively seal perforations, they
carry notable disadvantages including increased thrombosis risk, side branch
occlusion at the perforation site, and reduced flexibility. Furthermore, these
stents are not routinely available in all catheterization laboratories 9,10. Prolonged low pressure balloon inflation is the optimal initial
intervention CP, as it maintains vascular integrity while bridging to
definitive treatment. This approach preserves vascular patency and provide
critical time for emergency cardiac surgery. However, evidence based
recommendations are lacking regarding the ideal inflation site for optimal
perforation sealing. 11. This case presented with
two key risk factors for CP: diabetes and a CTO with a high procedural
complexity (J-CTO score 3). Perforation was attempted with prolonged balloon
inflation and emergency pericardiocentesis for tamponade; because of continued
instability, the patient was immediately transferred for surgical intervention.
Conclusion
CP represents a life-threatening
complication that may occur during complex PCI, particularly CTO procedures.
Interventional cardiologists must maintain expertise in early recognition and
management of CP. Surgical intervention should be considered without delay in
cases refractory to PCI.