A Series of Unfortunate Events
Dr. Erwin MULIA
65 year old Chinese lady with hypertension, diabetes mellitus and dyslipidemia and was noted to have 3VD and PCI to LCx (1 DES) was performed in 2011 (Movie 1, Movie 2, Movie 3, Movie 4). LAD lesion was not intervened because of the non-viable myocardium at LAD territory. She was doing well until 2015, when she presented with NSTEMI and coronary restudy +/- PCI was arranged, which showed similar LAD and RCA lesions as in 2011 with patent stent in LCx. The plan was for CABG and was pending in June 2016.
However, in March 2016, she was suffering from patella fracture requiring urgent orthopedic procedure. The initial plan for CABG was changed to early PCI. And at the same time, she developed upper GI bleeding and endoscopy confirmed of multiple gastric ulcers and PCI was delayed. After completing treatment for the GUs, coronary angiogram on May 2016 showed spontaneous dissection of RCA (Movie 5, Movie 6). The PCI was postponed for 2 months.
Procedure:
PCI was finally arranged on Jul 2016. RCA dissection was not healed. PCI to RCA was performed using Ikari L 3.5/6 Fr GC and Floppy GW. Predilation using 2.5×15 mm SC balloon. Stenting from dRCA up to pRCA using 3 overlapping DES (3.0×48 mm, 3.5×38 mm, 4.0×18 mm) were performed (Figure 1, Figure 2, Figure 3). During postdilation in between overlapping segment at mid-distal RCA, Ellis type 3 coronary perforation occurred (Movie 7).
Patient ran into cardiac arrest soon and immediate resuscitation and pericardiocentesis were done. Prolonged balloon occlusion, covered stent implantation, heparin reversal, and high dose of inotropes were given and pericardiocentesis removed 1000 mL of blood (Movie 8, Movie 9).
Though all efforts were done, we couldn’t save the patient.
Learning points:
Different severity of perforation (Figure 4) was managed differently (Figure 5). In this case of Grade 3 perforation, we had try our best to use all available methods (Figure 6) but still not able to save patient’s life.
Invasive imaging modality may give better understanding of dissected coronary artery lesion and treating the other significant lesion before treating long dissected lesion may be a better strategy.
The perforation point not very obvious with the current angiogram. Any other shot showing it more clearly ?
Unfortunate case.
1. What is the cause of the dissection? Spontaneous? Catheter induced? Looks fresh and appears to be extending with contrast injection.
2. What is the cause of the perforation.
Regards,
It appears to be a catheter induced RCA dissection. How long did it take between perforation and pericardiocentesis? Is it possible that the cover stent not covering the whole leakage area because 1L of blood in pericardium is alot in an acute case.
@Wong Christopher: unfortunately we didn’t capture the image…soon after we did contrast test, we were surprised by the perforation and we did step by step coronary perforation bail out strategy
@ Ramesh Singh: we first thought of spontaneous dissection…but when we reviewed back the first RCA angiogram in 2016 (before PCI) we could see it clearly that catheter induced dissection is highly probable to be the cause of the dissection…cause of perforation (1). over dilation of post dilation around the overlapping proximal and mid RCA (2). Coronary wire might go inside to and fro the false lumen in mid RCA back to true lumen in distal RCA and worsened after stenting and post dilation
@Henry Kok: yesss…we only had one covered stent left which was 3.5×12 mm (post dilation used 4.0×18 mm stent balloon up to 16 ATM)…and if the hypothesis is correct covered stent won’t help if the coronary wire already inside the false lumen going back to true lumen, predilated and stented afterwards…pericardiosintesis was performed around 5-10 minutes after the perforation in between CPR
Thank you all…regards