Puncture the Graft

85 years old lady has history of hypertension, DM and hyperlipidaemia presented with NSTEMI. Echocardiography showed poor EF 30% with global hypokinesia and mild MR. Despite of optimal medical treatment, she still had angina. Hence, she underwent coro +/- PCI. Coronary angiography showed ostial RCA CTO, short left main 50%, calcified ostial LAD 90%, mid LAD diffuse calcified disease and proximal LCX 90%. In view of recent NSTEMI, poor EF and severe triple vessels disease with high Syntax score, planned to have Impella assisted PCI to LM/LAD/LCX. (Figure 1, Figure 2)

Impella 2.5 was inserted via the left femoral artery. 7Fr JL4 guiding catheter engaged to left coronary artery via the right femoral artery. After predilatation, proximal LCX was stented with 2.5/15mm DES. Because of severe calcification in LAD, 1.25mm (then 1.5mm) rotablation blur was used to debulk the calcium. Post rotablation angiogram showed Ellis type III perforation at proximal LAD. (Movie 1)

Despite of prolonged balloon tamponade, perforation persisted. Distal left main to mid LAD then stented with 3.5/20 and 3.0/32mm DES. However, perforation still persisted despite DES stenting with worsening pericardial effusion that needed urgent pericardiocentesis. Finally, perforation was sealed with deployment of stent graft from proximal LAD to distal LM. (Figure 3)

After deployment of stent graft, LCX was closed and patient developed severe hypotension. ECG showed ST elevation. With jailed wire in LCX as landmark, supported by Crusade catheter, Conquest Pro 12 successfully punctured into LCX (Movie 2). With anchoring balloon technique, Caravel passed over the stent graft into the LCX and then exchange to soft wire. After 2.0mm balloon dilatation, TIMI3 flow in LCX resumed (Figure 4), followed by T stenting of LCX with 2.75/12mm DES and kissing balloon dilatation. After stenting, angiogram showed residual leakage at ostial LAD with persistent drainage of fresh blood from pericardiocentesis drain (Movie 3). Patient was undergone urgent surgery, but finally died of multi organ failure.

Lesson to learn:

In bail out situation, side branch jailed by stent graft can be reopened by CTO wire.

In lethal complication situation, pursuing a prefect angiogram result is hazardous.