Emergency Platinum Coil Embolization in a Coronary Artery Perforation with Tamponade During Abciximab Infusion in Acute Myocardial Infarction

This case describes a patient with an acute myocardial infarction treated with intravenous abciximab, primary angioplasty, rotablation, and stenting, who had a hydrophilic-coated guidewire-induced vessel perforation, leading to tamponade. Following successful percutaneous pericardiocentesis, leakage was controlled immediately with the delivery of a platinum coil into the perforation, thus avoiding emergency surgical intervention. In selected cases. placement of intracoronary platinum coils to seal guidewire-induced perforations might prevent the need of emergency surgical intervention, especially in highly anticoagulated patients or in those receiving glycoprotein IIb/IIIa blockers.     

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.     

Novel economic treatment for coronary wire perforation: A case report

BACKGROUNDCoronary artery perforation is a rare but potentially life-threatening complication of percutaneous coronary intervention (PCI), however if recognized and managed promptly, its adverse consequences can be minimized. Risk factors include the use of advanced PCI technique (such as atherectomy and chronic total occlusion interventions) and treatment of severely calcified lesions. Large vessel perforation is usually treated with implantation of a covered stent, whereas distal and collateral vessel perforations are usually treated with embolization of coils, fat, thrombin, or collagen. We describe a novel and cost-effective method of embolisation using a cut remnant of a used angioplasty balloon that was successful in sealing a distal wire perforation. we advocate this method as a simple method of managing distal vessel perforation.CASE SUMMARYA 73-year-old male with previous coronary Bypass graft operation and recurrent angina on minimal exertion had undergone rotablation and PCI to his dominant left circumflex. At the end of the procedure there was evidence of wire perforation at the distal branch and despite prolonged balloon tamponade there continued to be extravasation and the decision was made to seal this perforation. A cut piece of an angioplasty balloon was used and delivered on the original angioplasty wire to before the perforation area and released which resulted in sealing of the perforation with no unwanted clinical consequences.CONCLUSIONThe use of a balloon remnant for embolization in coronary perforation presents a simple, efficient and cost-effective method for managing coronary perforations and may be an alternative for achieving hemostasis and preventing poor outcome. Prevention remains the most important part with meticulous attention to the distal wire position, particularly with hydrophilic wires.     

Coil embolization for successful treatment of perforation of chronically occluded proximal coronary artery.

We describe a case of a coronary artery perforation involving the proximal right coronary artery that was successfully managed by percutaneous coil embolization. In the setting of a chronic coronary artery occlusion, this demonstrates the successful use of thrombogenic platinum alloy coils for a large proximal vessel perforation which has not been described previously.     

Oesophageal perforation following endoscopic variceal ligation and balloon tamponade

Endoscopic variceal ligation (EVL) related complication is rarely reported. A case is presented of a 74 year old man with oesophageal variceal bleeding who developed oesophageal perforation following EVL and balloon tamponade. An oesophageal wall defect was induced by EVL and tissue repair was hindered by decompensated liver reserve and shock status; concomitant balloon tamponade precipitated oesophageal perforation. The case is reported to draw attention to oesophageal perforation after concurrent use of balloon tamponade and EVL.     

Transluminal coronary angioplasty complicated by coronary artery perforation

Transluminal coronary angioplasty may be associated with complications resulting from the dilatation catheter and inflation of the balloon. The most common complications are dissection, occlusion, and coronary spasm. We report an unusual complication of coronary artery perforation by the dilatation catheter resulting in acute pericardial tamponade. The complication was immediately recognized and confirmed by dye injection and hemodynamic measurements. Pericardiocentesis was performed, followed by successful coronary bypass surgery. The reasons for the perforation are unclear. We postulate that the acute angle of the perforated vessel was an important factor for this complication. The importance of a standby cardiac surgeon and operating room is emphasized.     

冠状动脉介入治疗并发冠状动脉穿孔及心脏压塞的处理对策

目的　探讨冠状动脉介入治疗 (PCI)中并发冠状动脉穿孔及心脏压塞的处理对策。方法　对我院 1989年 9月至 2 0 0 3年 9月期间发生的冠状动脉穿孔病例进行回顾性分析。结果　共完成经皮腔内冠状动脉成形术 (PTCA)及支架 72 32例。发生冠状动脉穿孔 18例 ,发生率为 0 2 5 % ,多数发生于慢性完全闭塞性病变 (83 3% ) ,其中引导钢丝所致穿孔者 9例 ,球囊扩张后穿孔 7例 ,置入支架后穿孔 2例。 14例 (77 8% )穿孔为少量对比剂排至心包腔内或心肌内 ,其中 7例用球囊长时间低压力贴附封堵破口 ,穿孔征象消失 ;6例用鱼精蛋白静脉注射中和肝素 ,1例未做特殊处理 ,穿孔消失。4 (2 2 2 % )例发生急性心脏压塞 ,超声心动图显示有心包积液 ,紧急心包穿刺引流后病情平稳。 2例外科急诊修补血管破口 ,同时行冠状动脉旁路移植术 (CABG)。无一例死亡。结论　PCI并发冠状动脉穿孔少见 ,及时发现和正确处理是避免严重并发症的关键。     

Cardiac perforation complicated by cardiac tamponade and sealed with metallic coils

Distal coronary artery perforation with an angioplasty guidewire is a rare complication that may cause cardiac tamponade, myocardial infarction, arrhythmia, and even death. The use of platelet IIb/IIIa glycoprotein receptor inhibitors increases the risk of potentially fatal complications that are difficult to manage. We report a patient on treatment with abciximab who presented coronary perforation in a distal branch of the right coronary artery caused by the coronary guidewire tip, and complicated by acute cardiac tamponade. Blood extravasation to the pericardium was stopped by releasing two metallic coils into the distal vessel, thereby avoiding the need for emergent cardiac surgery.     

Covered stent implantation through a single 8‐french guide catheter for the management of a distal coronary perforation

Distal coronary perforation can cause early or late tamponade and is usually treated with fat or coil embolization. An alternative treatment strategy is occlusion of the ostium of the perforated vessel via implantation of a covered stent in the main vessel, which is typically achieved using the ping‐pong guide catheter technique. In this technique, a balloon is inflated over one guide catheter to stop pericardial bleeding and a covered stent is delivered through a second guide catheter due to inability to fit both a balloon and a covered stent through a single guide catheter. With development of lower profile rapid exchange covered stents, a single guide catheter can be used to both occlude the target vessel and deliver the covered stent. We describe a case of distal vessel perforation in which a balloon was inflated to stop pericardial bleeding, followed by delivery of a covered stent (Graftmaster, Abbott Vascular) through a single 8‐Fr guide catheter. This “block and deliver” technique represents a novel paradigm for treating coronary perforations through a single guide catheter, obviating the need for the ping‐pong guide catheter technique. © 2017 Wiley Periodicals, Inc.     

Treatment of rotablation‐induced ostial left circumflex perforation by papyrus covered stent and its fenestration to recover the left anterior descending artery during CHIP procedure

Coronary artery perforation is a rare complication of percutaneous coronary intervention (PCI). Covered stents have been successfully used in these situations. We report a case of ostial left circumflex (LCx) artery perforation during rotablation PCI of left main coronary artery (LMCA) and LCx artery. After failed attempts to balloon tamponade the perforation, a PK Papyrus covered stent was deployed from proximal LCx into LMCA. This resulted in acute exclusion of the left anterior descending (LAD) artery from coronary circulation. Using a dual lumen catheter, a stiff wire was advanced through the side port toward the occluded LAD to fenestrate the membrane of the covered stent. A series of balloons were used to dilate the fenestration in the covered stent to restore a normal flow into the LAD.     

Transcatheter recanalization of the left main pulmonary artery after four years of complete occlusion.

A technique for transcatheter "reconstruction" of a completely occluded left pulmonary artery using radiofrequency perforation with subsequent balloon dilation and stent implantation is reported in a 7-year-old child. It is shown that transcatheter radiofrequency perforation can still be effective years after the occlusion of a vessel.     

Esophageal perforation--associated risk with balloon tamponade after endoscopic therapy. Myth or reality?

BACKGROUND/AIMS: Variceal bleeding is still associated with high mortality and balloon tamponade may be a lifesaving measure when endoscopic therapy is not available or feasible. The risk of esophageal perforation with balloon tamponade after endoscopic therapy is still uncertain. The aims of the study were to investigate balloon tamponade effectiveness and safety after endoscopic therapy. METHODOLOGY: Retrospective analysis of 100 consecutive episodes of acute variceal bleeding treated with the Sengstaken-Blakemore tube. RESULTS: Balloon tamponade had an overall effectiveness of 61%. The Child-Pugh score was significantly higher in patients who failed balloon tamponade. In 48 cases balloon tamponade was preceded by failure of endoscopic therapy. Balloon tamponade was more effective if a previous attempt to perform endoscopic therapy happened (75% vs. 48%; p = 0.006). Aspiration was the most frequent complication. No cases of esophageal perforation were registered. CONCLUSIONS: Currently balloon tamponade is only used as a temporary bridge to other strategies, when other forms of hemostatic therapies do not succeed. Balloon tamponade was more effective in patients with less severe hepatic dysfunction. Previous attempts to perform endoscopic therapy may augment tamponade effectiveness without increasing the risk of esophageal perforation.     

Complete left atrial obliteration due to localized tamponade after coronary artery perforation during PTCA

Coronary artery perforation is a rare but important complication of percutaneous revascularization (PTCA). Clinical events following coronary perforation may include cardiac tamponade. After bypass graft operation (CABG), however, cardiac tamponade with subsequent hemodynamic instability is unusual due to the development of pericardial adhesions. We report an unusual case of localized tamponade after coronary artery perforation during PTCA in a patient with previous CABG. Cathet. Cardiovasc. Diagn. 45:61–63, 1998. © 1998 Wiley-Liss, Inc.     

Percutaneous closure of a left ventricular perforation post balloon mitral valvotomy.

The risk of left ventricular perforation is a rare but well-recognized complication of percutaneous double balloon mitral valvuloplasty that usually requires surgical bailout. We describe a case of left ventricular perforation with cardiac tamponade, caused by the propulsion of the balloons during balloon mitral valvotomy on an 86-year-old female with previous thoracotomies that was resolved using percutaneous coil embolization of the perforation. This approach to these types of complications, although unlikely to be of extensive use, will serve to expand the horizon of options in the field of interventions. Cathet. Cardiovasc. Intervent. 48:78-83, 1999.     

Delayed coronary perforation four days after percutaneous coronary intervention with subsequent cardiac tamponade: A case report

Coronary artery perforation (CAP) is a rare but lethal complication of percutaneous coronary interventions (PCIs), and its incidence has been increasing with advances in PCI techniques. Delayed CAP presents a highly challenging complication, as it occurs 30 min−9 days after intervention, making subsequent diagnosis and treatment difficult. We present the case of a 63-year-old male patient who underwent PCI for an obtuse marginalis II because of posterior wall myocardial infarction. Following 4 days of uneventful postoperative stay, the patient developed angina pectoris and hypotension 4 h after reinitiation of anticoagulant therapy with edoxaban. Angiography revealed distal vessel perforation from a side branch of the obtuse marginalis II. The vessel was occluded using autologous fat embolization via a microcatheter, resulting in complete sealing of the perforation. After discharge, 4 weeks after the infarction, the patient started rehabilitation therapy. Distal vessel perforations are typically caused by wire damage. In our case, we also suspected distal wire perforation, which was initially not recognized possibly due to distal occlusion through the thrombotic material. The temporal correlation between the re-initiation of anticoagulant therapy and the occurrence of cardiac tamponade suggests that the thrombotic material was resolved due to the former. The management of delayed CAP does not differ from that of CAP; thus, this rare complication should be considered even days after PCI as it could prove lethal if not recognized early.     

Delayed and recurrent cardiac tamponade following distal coronary perforation of hydrphilic guidewires during coronary intervention

Coronary artery perforation is a rare complication of percutaneous coronary intervention, but can result in cardiac tamponade and is thus potentially life-threatening. It is well recognized that the use of hydrophilic wires during interventional procedures increases the risk of coronary perforation. We report two cases in which a particular looping configuration was suspected of causing vessel laceration with subsequent development of pericardial effusion and tamponade. In one case, tamponade occurred several days after the index procedure, mimicking acute myocardial infarction. In the second case, tamponade was successfully treated with immediate pericardial drainage, but tamponade recurred several days later.     

Left internal mammary artery graft perforation due to high-pressure stent deployment

Perforation of newly placed left internal mammary artery (LIMA) grafts due to stent deployment is an infrequent but potentially dangerous complication of coronary interventions. It may lead to brisk hemorrhage and massive cardiac tamponade requiring emergent pericardiocentesis and surgery. We report a case of a LIMA graft perforation following stent deployment with a high-pressure balloon 12 days after surgery. The patient was treated with emergent pericardiocentesis, rapid autotransfusion of the pericardial aspirate into the systemic circulation, and surgical repair of the ruptured vessel. Cathet. Cardiovasc Intervent. 47:199–202, 1999. © 1999 Wiley-Liss, Inc.     

Left atrial inflow and outflow obstruction as a complication of retrograde approach for chronic total occlusion

Retrograde recanalization of a chronic coronary total occlusion has become an increasingly utilized method to increase success from percutaneous coronary intervention (PCI). Retrograde wire passage using a septal collateral is the preferred route as the consequences of vessel perforation are more benign than epicardial collateral perforation which may produce cardiac tamponade. Tamponade risk is thought to be lessened by previous coronary bypass surgery due to adhesions preventing free flow of blood throughout the pericardial space. We report the first case of the retrograde approach producing epicardial collateral perforation resulting in a localized epicardial hematoma, which in turn, produced left atrial (LA) inflow and outflow obstruction, with the former producing localized pulmonary edema and pleural effusion. We review reported cases of LA hematoma as a consequence of the antegrade PCI approach and describe a unified explanation for the development of this phenomenon. © 2012 Wiley Periodicals, Inc.     

Percutaneous saphenectomy: a potentially dreadful complication of cutting balloon angioplasty in saphenous vein grafts

Vessel perforation is an uncommon but potentially life-threatening complication of percutaneous coronary intervention and is often associated with the use of atheroablative devices. While effective management means are currently available, such as PTFE-covered stent, pericardiocentesis, and perfusion balloon, a timely and skillful approach is of paramount importance to solve this dreadful complication. We hereby describe a case of saphenous vein graft (SVG) perforation occurring after cutting balloon angioplasty for in-stent restenosis. Despite the immediate occurrence of cardiac arrest due to massive extravasation of contrast in the mediastinum with pericardial tamponade, deep catheter intubation enabled the deployment of two PTFE-covered stents and subsequent sealing of the leak with repeated inflation of a perfusion balloon, while hemopericardium was drained by pericardiocentesis. This clinical vignette emphasizes the role of optimal backup in order to deploy life-saving devices and successfully manage life-threatening pericardial tamponade due to SVG rupture.     

Cardiac tamponade following coronary arterial rupture during coronary angioplasty

We describe a patient in whom percutaneous transluminal coronary angioplasty (PTCA) was complicated by rupture of the left anterior descending coronary artery (LAD) with pericardial tamponade. The outcome was favorable with drastic intervention which included: occlusion of the bleeding vessel with the PTCA balloon, pericardiocentesis, and ligation of the vessel without the need of aortocoronary bypass graft.