Successful treatment of coronary artery perforation in an abciximab-treated patient by microcoil embolization.

We describe a case of type 2 coronary artery perforation in a 73-year-old man undergoing coronary artery rotablation and stenting with abciximab therapy. The coronary artery perforation was successfully treated by coil embolization with Trufill pushable coils made from platinum alloy and synthetic fibers to promote maximum thrombogenicity.     

The balloon occlusion and thrombus aspiration catheter mediated-distal coronary perfusion technique (BI-RESCUE) for treatment of coronary artery perforation

Coronary artery perforation(CAP)remains an infrequent but potentially lifethreatening complication during percutaneous coronary intervention(PCI).Although the prevalence of CAP is about 0.2%?0.9%in relatively low risk PCI,the incidence could up to 9%in complex clinical scenarios such as severe coronary calcification,chronic total occlusions and rotational atherectomy.[1]Despite the new techniques and equipment had lower morbidity and mortality,up to 17%of acute CAP cases would evolve to tamponade and subsequent death.     

Successful treatment of distal coronary guidewire-induced perforation with balloon catheter delivery of intracoronary thrombin.

Distal coronary artery perforation with a coronary guidewire is a relatively rare but potentially fatal complication during PTCA. Historically, these types of perforations have been easy to control with reversal of heparin anticoagulation combined with prolonged distal balloon inflation. In the modern era, with widespread use of potent glycoprotein IIb/IIIa inhibitors, this type of distal wire perforation has become more difficult to manage and potentially lethal. In this article, we report two cases of guidewire-related distal coronary artery perforation, successfully treated using a new technique using localized, distal intracoronary thrombin injection. During prolonged low-pressure balloon inflation, a small dose of thrombin was injected just proximal to the wire perforation site via the lumen of a coronary balloon catheter. This approach appears to be a relatively rapid and effective way to control this troublesome complication.     

Successful collapse vessel treatment with a syringe for thrombus-aspiration after the guidewire-induced coronary artery perforation

Coronary artery perforation is a rare however potentially life-threatening complication of percutaneous coronary intervention that could cause cardiac tamponade. It requires emergent surgery unless an appropriate procedure is performed immediately. In distal coronary artery perforations with guidewires, several procedures were reported to be effective in refractory cases after prolonged balloon inflation and reversal of heparin by protamine sulfate to induce hemostasis. We describe a case of successful collapse distal coronary artery treatment with a syringe for thrombus-aspiration without materials for an embolization after guidewire-induced coronary artery perforation.     

Successful treatment of iatrogenic renal artery perforation with an autologous vein-covered stent.

A 72-year-old woman developed severe flank pain associated with hemodynamic compromise immediately after a J-curve guidewire was inadvertently advanced into the right renal artery during cardiac catheterization. Contrast extravasation consistent with perforation of the main renal artery was seen on abdominal angiography. The perforation was successfully sealed using a premounted coronary stent that was covered with an autologous antecubital vein. Wide stent patency without aneurismal dilatation was confirmed on a 2-year follow-up renal angiogram.     

Successful sealing of a coronary artery perforation with a mesh-covered stent

Coronary artery perforation is a rare, but particularly feared and sometimes life-threatening, complication of percutaneous coronary interventions. The incidence of coronary perforation has increased with newer, more invasive interventional devices and techniques like rotablation, excimer laser coronary angioplasty, routine high-pressure balloon dilatation, or chronic total occlusion interventions. Here we describe a case of Ellis grade 2 perforation following a balloon dilatation performed in an in-stent restenotic total occlusion. The perforation was successfully sealed with a recently introduced device, a mesh covered stent (MGuard stent, Inspire MD). This new stent is much more flexible than the polytetrafluoroethylene-covered stent, which is often implanted in Ellis 2 or 3 grade perforations.     

Successful treatment of coronary artery perforation during angioplasty using autologous vein graft-coated stent

We report a case of successful treatment of coronary arteryperforation and cardiac tamponade with an autologous vein graft-coatedstent, which were developed during percutaneous transluminalcoronary angioplasty. The method reported here may be an effectivealternative to emergency surgery and should be considered whencoronary artery perforation does not respond to conventionalprolonged inflation with perfusion catheter.     

Successful treatment of coronary artery perforation during angioplasty using a new membrane-coated stent

We report a case of successful treatment of coronary artery perforation and cardiac tamponade, which developed during percutaneous transluminal coronary angioplasty, with a PTFE-coated stent. Intravascular ultrasound was first used to overcome the shortcomings of conventional angiography and overlapping of a conventional stent was not as effective as coated-stent placement in sealing a further leakage. Thus, PTFE-coated stents may be an effective alternative to emergency surgery or autologous venous covered stenting and should be considered when coronary artery perforation occurs.     

Successful management of coronary artery perforation with helical platinum microcoil embolization.

A case of small coronary artery perforation during coronary intervention is presented. Continued leakage occurred despite prolonged intracoronary balloon inflation, in part probably related to the use of glycoprotein (GP) IIB/IIIA inhibitors. It was successfully managed by microcoil embolization without any sequel, helping avoid surgery in a high-risk patient. Cathet. Cardiovasc. Intervent. 51:320-322, 2000.     

Successful closure of coronary artery perforation using non-conventional embolic material

Coronary perforation during percutaneous coronary interventions is a rare but dreadful complication. While coronary perforation involving large vessels are managed successfully by covered stents, small distal vessel perforation is usually managed by prolonged balloon inflation or embolization of gel foam/thrombogenic metallic coils. We describe a case, where perforation of a small ventricular branch of the right coronary artery was successfully occluded by packing it with pieces of thrombogenic floppy tips of used coronary angioplasty guidewires instead of conventional metallic coils.     

Successful closure of coronary artery perforation using makeshift stent sandwich.

An elderly woman underwent stenting of mid left anterior descending coronary artery (LAD) 2 days after myocardial infarction. During high-pressure stent dilatation, vessel perforation was noted. We assembled a "stent sandwich" in the cardiac catheterization laboratory and used it successfully to seal the perforation with good angiographic result. Although the long-term patency remains an issue, this case demonstrates the feasibility of using makeshift covered-stent as a bailout for arterial perforation in selected cases where emergency thoracotomy is undesirable.     

Successful percutaneous interventions with limited crossing of the penetration catheter into severe coronary artery stenoses

The novel Tornus penetration catheter, which has recently been approved by the FDA, is designed to cross difficult coronary lesion types such as chronic total occlusions. Published case studies on the Tornus have all demonstrated successful lesion crossing by the penetration catheter, thereby allowing for optional guidewire exchange and successful procedural outcomes. In the present two case reports, the penetration catheter demonstrates its effectiveness in the necessary guidewire exchange for rotational atherectomy without fully crossing the coronary lesions. In advanced coronary stenoses such as those with chronic total occlusions, severely stenotic, heavily calcified, long, diffuse lesions, the ability to perform guidewire exchange with only limited or partial lesion penetration with the Tornus device is invaluable. This facet of the penetration catheter adds to the overall armamentarium of options in the percutaneous treatment of advanced coronary artery stenoses.     

Successful use of a balloon catheter to facilitate guidewire placement in an occluded coronary artery with extreme angulations

The present report describes the case of a 77-year-old man with unstable angina, in which the culprit vessel was extremely angulated and precluded placement of a guidewire for subsequent coronary interventions. A novel technique is reported, using an undersized, uninflated and distally placed balloon catheter, which easily facilitated guidewire placement.     

Successful retrieval of a broken intravascular ultrasound catheter tip in the coronary artery

We report the successful retrieval of a broken intracoronary intravascular ultrasound (IVUS) catheter tip that was mostly invisible on fluoroscopy by using a snare catheter and pulling from distal to proximal. An 80-year-old male had presented with effort-related angina for one month. A coronary angiogram revealed severe stenosis of the proximal portion of the left anterior descending artery (LAD). Percutaneous coronary intervention (PCI) was planned for the lesion. During pre-procedural IVUS examination, the IVUS catheter fractured leaving the tip of the IVUS catheter inside the LAD. An attempt was made to remove the IVUS catheter tip by engaging the free proximal end of the tip with a loop snare. This attempt failed due to the free proximal end of the IVUS catheter tip being invisible on fluoroscopy. A loop snare was instead delivered distal to the IVUS catheter tip through a microcatheter, and the IVUS wire of the catheter tip was manipulated into the loop. The loop snare was then pulled back securely catching the IVUS catheter tip. The broken IVUS catheter tip was subsequently removed. This novel technique is effective for retrieving intracoronary foreign bodies.     

Coronary perforation after excimer laser coronary angioplasty: The excimer laser coronary angioplasty registry experience

Objective. This study assessed the frequency of perforation with excimer coronary angioplasty.Background. Coronary artery perforation after conventional percutaneous trasluminal coronary angioplasty is extremely rare. Because laser coronary angioplasty involves actual tissue ablation, it has an Increased potential for perforation.Methods. All patients in the Excimer Laser Coronary Angioplasty Registry were included in this prospective study. Those who had a perforation related to the procedure were compared with those who did not have this complication.Results. Of 2,759 consecutive patients in the Excimer Laser Coronary Angioplasty Registry, 36 (1.3%) had perforation. In these patients, the left anterior descending coronary artery was the most frequently treated vessel (53%). There were no differences in fiber sizes between patients with and those without perforation. Among the patients with perforation, 36.1% required coronary artery bypass surgery, 16.7% experienced an infarction and 5.6% had a fatal outcome. Among the patients without perforation, the rates were 3.1%, 3.8% and 0.6%, respectively. However, 41.7% of the patients with documented coronary artery perforation did not need coronary artery bypass surgery or experience myocardial infarction or death. No angiographic characteristics distinguished lesions with from those without perforation. The frequency of coronary artery perforation declined over time with increasing operator experience, from 1.6% in the first 1,888 patients to only 0.4% in the last 1,000 patients (p = 0.002).Conclusions. With increasing operator experience, the rate of perforation with excimer laser coronary angioplasty has decreased. When perforation occurs, subsequent event rates increase.     

Benefit of the perfusion catheter for emergency coronary artery grafting after failed percutaneous transluminal coronary angioplasty

Of 2,102 consecutive patients who underwent percutaneous transluminal coronary angioplasty, 31 (1.5%) had emergency coronary bypass grafting for failed angioplasty. To determine the potential impact of different therapeutic strategies for controlling associated myocardial ischemia, 3 groups were analyzed. Group 1 comprised 11 patients (36%) in whom a "bailout" catheter was used to maintain anterograde coronary perfusion, group 2 included 16 patients (52%) in whom only intraaortic balloon counterpulsation was used and group 3 contained 4 patients (13%) in whom neither bailout catheter nor intraaortic balloon was used. Despite a longer average time to cardiopulmonary bypass, patients managed with the bailout catheter had a significantly lower incidence of Q-wave myocardial infarctions (9 vs 75%, p less than 0.05) compared with patients managed with intraaortic balloon counterpulsation alone. Those managed with the bailout catheter also had more consistent resolution of ST elevation and greater use of internal mammary artery grafts than patients supported by intraaortic balloon counterpulsation alone.     

Long-tip guiding catheter: Successful and safe for left coronary artery angioplasty

A long-tip guiding catheter was designed for angioplasty of the left coronary artery. Principal factors of guiding catheter function were identified, and the catheter's shape was designed to utilize them efficiently. Emphasis was placed on an overbent secondary curve (150–180°) for more precise catheter control. The distal tip of the catheter is 2 cm long in the 4.0 size and the primary bend is shallow, ～20%. A 1.5 cm long segment between the secondary and tertiary curves enhances stability and support. Catheter performance was studied during procedures on 90 patients; 89 patients underwent coronary artery angioplasty and one patient underwent diagnostic angiography. The success rate for angioplasty was 95% with no major complications. Mild pressure damping occurred in 18 patients, and mild catheter displacement from the left main coronary artery occurred in 24 patients. Catheter support was judged as excellent to very good in 82 patients. Judkins or Amplatz catheters were not required during this study. The observed disadvantages of the long-tip catheter were the risk of catheter buckling up during advancement into the left main coronary artery and, perhaps, a higher risk of pressure damping. Superselective engagement of the catheter in the left anterior descending or circumflex arteries may be a problem when the left main coronary artery is very short. This study showed the long-tip catheter to be safe and highly successful for angioplasty of the left coronary artery.     

Successful percutaneous treatment of anomalous left coronary artery from pulmonary artery

Anomalous origin of the left main coronary artery from the pulmonary artery (ALCAPA) is an uncommon congenital condition seen in the adult population, with most patients developing symptoms in infancy. We describe successful closure of an ALCAPA in an adult using a percutaneous transcatheter approach in a patient with evidence of anterior wall ischemia believed to be the consequence of myocardial steal. A 30-year-old female was noted to have continuous flow in the right ventricular septum on transthoracic echocardiography, with subsequent imaging confirming the presence of an ALCAPA. Myocardial perfusion imaging confirmed anterior wall ischemia, and as a strategy to optimize coronary perfusion pressure, the patient underwent percutaneous ALCAPA closure using an Amplatzer vascular plug. The procedure was well tolerated, with no evidence of anterior ischemia or myocardial dysfunction. Follow up perfusion imaging demonstrated no residual anterior wall ischemia. Transcatheter closure of an ALCAPA is a potentially safe and effective alternative treatment strategy in this patient population.