Subacute left main coronary stenosis: an unusual but serious complication of percutaneous transluminal coronary angioplasty

Percutaneous transluminal coronary angioplasty (PTCA) is a proven nonoperative method of direct myocardial revascularization. Acute complications occurring during PTCA center primarily around acute disruption at the site of dilatation, arrhythmias, or vascular problems at the site of guide catheter access. Late complications include restenosis or aneurysm formation at the site of dilatation. Subacute stenosis of the left main coronary artery occurred in three of 440 patients who had PTCA performed between September 1980 and December 1983 and may be an infrequent but potentially critical complication of PTCA. The serious clinical course of patients with left main coronary stenosis requires prompt recognition and intervention.     

Novel use of a local drug delivery catheter for coronary perforation

Coronary perforation is a complication of percutaneous coronary intervention that may be fatal. Conventionally, a perfusion balloon catheter is used for treatment, but may not always be available. We report a case in which bleeding due to coronary perforation was successfully treated without induction of ischemia using a local drug delivery catheter as a perfusion device.     

Coronary perforation as a potential complication derived from coronary thrombectomy with the X-Sizer device.

We report a case of coronary perforation after failed atherectomy with a 2 mm X-Sizer catheter in recent totally occluded right coronary artery. The perforation was successfully managed with a polytetrafluoroethylene-covered stent with satisfactory final angiographic results. Possible predictors of this complication with this new device are discussed.     

Percutaneous perfusion of occluded coronary arteries with blood from the femoral artery: a dog study

The idea of perfusing the distal coronary artery with arterial blood during balloon dilatation was implemented in early experimental coronary angioplasty but then abandoned. We pursued this concept in an animal model using a specially designed roller pump. The pump delivers blood from a femoral artery catheter through the central lumen of a balloon catheter occluding a coronary artery. Perfusion of large proximally occluded coronary arteries for at least 60 min was possible in 8 of 11 heparinized dogs. Hemolysis occurring in the pump system due to the small catheter lumen proved a minor problem. For a limited period of time, occluded coronary arteries can be adequately perfused with arterial blood by this percutaneous system that is readily applicable in any catheterization laboratory. Its use is conceivable not only for temporary treatment of acute complications during angioplasty but also for prolonged balloon dilatations of spastic or thrombosed coronary arteries.     

Angioplasty techniques for stenoses involving coronary artery bifurcations

Branch occlusion during coronary angioplasty is an infrequent but potentially serious complication. The overall incidence of branch occlusion during dilatation of a primary vessel is 5%. Branch vessels most jeopardized by dilatation generally have a complex plaque that not only involves the target vessel but also extends into the origin of the branch vessel. Branches free of pathology at their origin generally have an exceedingly low incidence of occlusion during adjacent balloon dilatation. Side branches at risk for occlusion should be "protected" if the branch vessel is of an important size that could be dilated with a conventional dilatation catheter. The advent of lower profile dilatation catheters and guidewires has provided an opportunity to introduce several pieces of dilatation hardware into the coronary system through a single guiding catheter. Several techniques are described for both "protecting" and dilating side branches, either simultaneously or secondarily, after balloon dilatation of a primary vessel.     

Successful treatment of an excimer laser-associated coronary artery perforation with the Stack perfusion catheter

A 64-year-old woman underwent excimer laser angioplasty of the right coronary artery. The procedure was complicated by perforation, which was successfully managed without complication with a Stack perfusion catheter. This report describes successful nonsurgical treatment of laser-induced coronary perforation and makes recommendations for avoiding this complication in other patients.     

Delayed appearance of coronary artery perforation following cutting balloon angioplasty.

Coronary artery perforation is a potential complication of percutaneous coronary intervention (PCI). It usually develops immediately following PCI, particularly when an atheroablate device is used. We report a case in which coronary artery perforation developed 4 days after PCI with a nondebulking device, a cutting balloon catheter.     

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.     

Deep intubation of 8 Fr guiding catheter to deliver coronary stent graft to seal coronary perforation: a case report.

Coronary perforation is an uncommon complication of angioplasty and is a challenging situation to manage. We describe a case of complex multivessel coronary angioplasty complicated by coronary perforation following balloon rupture that was successfully managed with a coronary stent graft. Delivery of the stent graft to the site of vessel rupture required deep intubation of an 8 Fr guiding catheter over the shaft of an inflated balloon. In addition to the availability of covered stents, it is essential to be familiar with various skills necessary to deploy these stents. Cathet Cardiovasc Intervent 2001;54:59-62.     

A novel method to bail out coronary perforation: Micro‐catheter distal perfusion technique

Coronary perforation is a rare, but life‐threatening complication during percutaneous coronary intervention. Prolonged balloon inflation is one option for achieving hemostasis, but it often causes ST elevation, chest pain, decreased blood pressure, or fatal arrhythmia due to ischemia. We present the case of a 73‐year‐old woman who suffered severe coronary perforation after stent implantation and post‐dilatation. To allow prolonged balloon inflation without ischemia, we perfused the distal area with the patient's own arterial blood injected via micro‐catheter. With this method, we could prolong balloon inflation for 20 min, successfully achieving hemostasis. This novel technique, which we named the “distal perfusion technique,” is useful to minimize ischemia during prolonged balloon inflation. © 2015 Wiley Periodicals, Inc.     

Conservative management of the perforation of a side branch of the left main coronary artery during coronary angiography

We report perforation of a side branch of left main coronary artery during coronary angiography. We suppose that the engaging of the catheter into a small side branch caused this complication. Furthermore, we observed that the conservative approach might be successful in the restoration of such coronary artery perforations. To the best of our knowledge this is the first reported case of left main side branch coronary artery perforation during angiography.     

Gelfoam embolization of a distal coronary artery guidewire perforation.

A guidewire-induced distal coronary artery perforation presenting with cardiac tamponade was occluded by distal Gelfoam embolization via an infusion catheter. This extends the treatment options for this rare complication of coronary interventional procedures. Cathet. Cardiovasc. Intervent. 49:214-217, 2000.     

Death from coronary air embolism during percutaneous transluminal coronary angioplasty

A patient undergoing percutaneous transluminal angioplasty of a critical proximal stenosis of his anterior descending coronary artery died as a result of coronary air embolism from a defective dilatation catheter. The probable mechanism responsible for this lethal complication is discussed. Simple precautions are described that will prevent its future occurrence.     

Guidewire‐Induced coronary perforation successfully treated with subcutaneous fat embolisation: A simple technique available to all

A 62‐year‐old man presented with an anterior ST elevation myocardial infarction and underwent primary percutaneous coronary intervention to an occluded diagonal artery. Following stenting, a type III distal guidewire‐induced coronary perforation of the diagonal branch was recognized with extravasation of contrast into the pericardial space. Prolonged balloon inflations proximal to the site of the perforation were unsuccessful. Subcutaneous fat was therefore harvested from the patients upper thigh under local anesthetic and embolized through an Export catheter into the distal diagonal vessel, resulting in the immediate cessation of leak through the site of perforation. We discuss the technical aspects of this technique as well as alternative methods of distal embolization and the potential complications that must be considered. © 2015 Wiley Periodicals, Inc.     

Prolonged coronary splinting in the management of acute coronary closure.

Acute closure is an infrequent but serious complication of PTCA that is often unsuccessfully treated by repeat dilatation. Two patients with acute closure refractory to repeat conventional PTCA were treated with prolonged coronary "splinting" using low-pressure reperfusion catheter balloon inflations of 11 and 15 h duration. The patients developed no chest pain or ST-segment changes during this period. The serum creatine kinase rose to 738 and 372 U/L, respectively. Neither patient evolved a Q-wave myocardial infarction. Both patients remain asymptomatic after 6 months of follow-up.     

Prolonged coronary splinting in the management of acute coronary closure

Acute closure is an infrequent but serious complication of PTCA that is often unsuccessfully treated by repeat dilatation. Two patients with acute closure refractory to repeat conventional PTCA were treated with prolonged coronary “splinting” using low-pressure reperfusion catheter balloon inflations of 11 and 15 h duration. The patients developed no chest pain or ST-segment changes during this period. The serum creatine kinase rose to 738 and 372 U/L, respectively. Neither patient evolved a Q-wave myocardial infarction. Both patients remain asymptomatic after 6 months of follow-up.     

An avoidable complication of percutaneous coronary intervention-entrapment of stent and disconnected balloon catheter

During percutaneous coronary intervention, entrapment of catheter materials is a rare but life-threatening complication that sometimes requires emergency surgical treatment. Coronary artery stents have been developed to prevent acute coronary closure and reduce restenosis after coronary angioplasty. The most frequently reported complications of coronary stents are related to stent thrombosis and anticoagulation problems. This case study describes a 60-year-old female who had stable angina pectoris and underwent stent insertion into the left circumflex artery. Unfortunately, the coronary stent with balloon catheter was entrapped while crossing the angulated segment between the left circumflex and left main coronary artery. The stent catheter was surgically removed, and the patient underwent coronary artery bypass grafting successfully. Physicians should keep in mind that extremely angulated segments may reduce the successful rate of coronary stenting and contribute to the stent entrapment complication.     

Acute pleuropericarditis after coronary stenting: a case report.

A case of acute pleuropericarditis, which occurred after apparently successful percutaneous coronary intervention (PCI) for chronic total occlusion of the right coronary artery, is reported. The patient underwent coronary stenting without any immediate signs of complications. However, he had an acute onset of chest pain with fever which happened 4 h after PCI. He was diagnosed with acute pleuropericarditis by blood tests, electrocardiogram, chest X-ray, and echocardiogram. He rapidly recovered by intravenous hydrocortisone followed by oral prednisone administrations and percutaneous catheter pericardial drainage. Acute pleuropericarditis relevant to post-cardiac injury syndrome with an atypically early onset might have occurred in this case as a rare complication of PCI.     

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.     

Directional coronary atherectomy for the treatment of coronary lesions with abnormal contour

Directional coronary atherectomy is a newly developed percutaneous transluminal procedure which excises and removes obstructive tissue from coronary arteries or saphenous vein grafts. This procedure was performed on 47 lesions with abnormal contour; 24 ulcerative lesions, 10 lesions with dissection, 7 flap-like lesions and 6 lesions with aneurysm dilatation. Overall success rate was 89%; 96% in ulcerative lesions, 70% in lesions with dissection, 86% in flap-like lesions and 100% in lesions with aneurysmal dilatation. Complications with this procedure were as follows: Vessel occlusion in 2 patients (4.5%), perforation in 1 patient (2.3%), and guiding catheter induced dissection in 1 patient (2.3%). Coronary artery bypass surgery was required in 4 patients (9.4%) for these complications. Of these, 3 patients had lesions with dissections prior to the atherectomy procedure. The success rate for lesions with abnormal contour was similar to those of 270 lesions with normal contour. In conclusion, directional coronary atherectomy is a safe and effective procedure for lesions with abnormal contour, however, outcome of a lesion with dissection is suboptimal and it needs to be approached cautiously.