Abstract

A fifty-year-old female with recent history of LAD stent placement for instent restenosis, presented with chest pain and ventricular fibrillatory arrest. Angiography revealed total occlusion of her LAD stent. She underwent IVUS study, balloon angioplasty and stent placements. Post balloon dilatation of the under-deployed distal stent resulted in dual coronary artery perforations with extravasation of contrast into the LV cavity, a Type 4 Ellis coronary artery perforation (CAP). No extravasation was noted into the pericardium. Immediately a covered stent was deployed which completely sealed both perforation sites with resultant TIMI grade 3 flow. Under-deployment of stents is a common occurrence and is underappreciated. It can happen due to various reasons. Not many options exist at that time but to use a high pressure balloon and post dilate the stent. One rare complication is CAP due to post stent dilatation, with incidence reported as 0.1% to 3.0% of PCI procedures. Among the various type of CAP, Ellis Type 4 is of the least frequent however no studies have looked at its exact incidence rate. Prompt recognition and quick intervention are essential to good patient outcome. We chose to deploy a covered stent over the perforation with interim balloon tamponading. Deployment of the stent successfully sealed both the CAPs. Remarkably the patient remained stable and did not complain of chest pain throughout the procedure. The patient did well; she was discharged on dual antiplatelet therapy and is continuing to do well. We report a rare case of 2 distal LAD perforations that drained into the LV (an Ellis Type 4 CAP) caused by post stent dilatation that were successfully treated with a single covered stent. We report successful management of this case along with review of literature about management and dilemmas encountered is such instances.

Highlights

  • The patient is a fifty-year-old female with a past medical history notable for congestive heart failure, hypertension and hyperlipidemia

  • Review of the literature cites a number of predisposing risk factors including advanced age, female gender, hypertension, hyperlipidemia, diabetes, chronic renal failure, history of prior coronary artery bypass graft (CABG), heavy coronary artery calcification, chronic total occlusion, tortuous vessels, target lesions in the circumflex and right coronary arteries, long target lesions (>10 mm), eccentric lesions, and small vessel size amongst others [2]

  • During percutaneous coronary intervention (PCI), coronary artery perforation may occur as a consequence of hydrophilic or extra stiff guide wire advancement, excessive over-dilation of a stent under high pressure or use of an oversized stent with high-pressure balloons, use of an atheroablative device, laser angioplasty, or intravascular ultrasound study (IVUS) catheter use for PCI optimization [1]

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Summary

Introduction

The patient is a fifty-year-old female with a past medical history notable for congestive heart failure, hypertension and hyperlipidemia. In October of 2013, she presented with chest pain (CP) and underwent coronary angiography It revealed in-stent restenosis along the entire length of the previously placed BMS. She was re-stented with a 2.25 × 32 mm Promus Element (0.081 mm) drug eluting stent (DES) and was discharged on aspirin and prasugrel along with her other cardiac medications. An intravascular ultrasound study (IVUS) revealed underdeployment of the LAD stent (Figure 3) with residual disease proximal and distal to the stent She underwent balloon dilatation of the underdeployed stent. Follow up angiography revealed two coronary perforations at the overlap region of the previously placed Integrity, Promus, and proximal aspect of the newly deployed distal Resolute stent with extravasation of contrast into the LV cavity (Figure 4, Figure 5).

Discussion
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