Rescuing a Bifurcation Perforation – Every Step Matter
Dr. Adrian LUK
A 70-year old hypertensive gentleman was a heavy smoker. He complained of effort angina for which an exercise treadmill test was performed and was positive. Coronary angiogram showed moderate proximal LAD diffuse disease. The mid-LAD had a significant calcified and angulated lesion (Movie 1). The second diagonal branch was a large branch with ostial disease. There was only mild disease in the LCX and RCA. IVUS could not pass the mid-LAD lesion. An IVUS pullback from the D2 showed the reference diameter of LAD proximal to the lesion was ~4.0mm. The mid-LAD was then pre-dilated with a 2.5mm NC balloon but the result was suboptimal. The mid-LAD was then dilated with a 3.25x10mm cutting balloon at 6-12atm. However, it resulted in a type 3 mid-LAD perforation (Movie 2). A 3.0x15mm balloon was quickly inflated at the D2 across the mid-LAD, occluding blood flow to the mid-LAD (Movie 3). The perforation site might be at the mid-LAD. Hence, a 2.5x20mm covered stent was attempted to place in the mid-LAD but it failed to advance across the stenosis. A 2.5x15mm balloon was rapidly exchanged into the mid-LAD and repeatedly dilated to better prepare the LAD lesion, while the 3.0x15mm NC balloon was parked at proximal LAD to D2 and inflated periodically as it allowed, preventing excessive leakage from the perforation. Eventually, a 3.0x26mm covered stent was able to be deployed at the mid-LAD just distal to D2 (Movie 4). Post-deployment angiogram showed the perforation was sealed by the covered stent. A 3.5x38mm DES was then implanted from proximal LAD into the D2 across the mid-LAD using the T-stent technique (Movie 5). The LAD was then rewired. Kissing balloon inflation was performed with a 3.5mm NC balloon in D2 and a 3.0mm NC balloon in mid-LAD. The mid-LAD covered stent was further post-dilated with a 3.5mm NC balloon. Final angiogram showed TIMI 3 flow to the distal LAD and D2, a sealed-off perforation, but loss of some of the septal branches (Movie 6). Echocardiogram showed minimal pericardial effusion. The patient remained hemodynamically stable and was discharged 3 days later.
This case has demonstrated how to manage a coronary perforation involving a bifurcation; especially it involves a major side branch. Balloon tamponade through periodic balloon inflations from a proximal segment into a side branch can prevent excessive leakage and, at the same time, allow lesion preparation and deployment of a covered stent. Sometime it is difficult to locate the exact site of the perforation. It will be better to deploy a covered stent distal to the take-off of the side branch first to preserve the significant side branch. If the perforation is exactly at the bifurcation, sometimes the only bailout solution is to deploy the covered stent across the bifurcation, sacrificing the side branch. Moreover, it is also important to have sequential careful balloon pre-dilatation of calcified and angulated lesions, avoiding the use of “over-sized” cutting balloon at high pressure.