Safely Save an Ellis Type 3 Perforation with One Guiding Catheter

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

73 year-old gentleman with history of hyperlipidemia, TIA, IFG, complained of exertional angina. CT coronary angiogram showed severe TVD. Coronary angiogram showed calcified mid-LAD stenosis and LCx stenosis. Blocked distal RCA retrogradely filled by left-to-right collaterals (Movie 1, Movie 2, Movie 3, Movie 4).

RCA was dominant and quite anteriorly take off. There was also diffusely disease from proximal to distal RCA, and the distal RCA was blocked and PDA, rPAV filled by collaterals from LAD. We plan to open up RCA CTO first.

The patient got a tortuous abdominal aorta, we decided for bifemoral approach. A long 8Fr right femoral sheath was inserted and 8Fr AL GC to engage RCA. Another 5Fr diagnostic JL4 was put into left femoral artery for retrograde injection. A Sion wire loaded with a corsair was able to cross RCA occlusion and passed to first posterolateral segment, then exchange with grand slam (Movie 5).

IVUS showed the RD of distal RCA was 2.25-2.5mm. Distal to mid-RCA was predilated with 2.25x15mm balloon. A 2.5x.38mm DES was deployed in the distal RCA at 12tam and postdilated proximally at 15atm.

Repeated angiogram showed a type 3 perforation at the distal RCA (Movie 6, Movie 7). The stent balloon was quickly delivered to the distal RCA and inflated to occlude the flow.

Repeated antegrade and retrograde injection showed no contrast extravasation. In view of type 3 perforation, prolonged balloon inflation is unlikely to seal off the perforation. Traditionally, we can have another GC to RCA with pingpong technique and do the wiring and put in a cover stent at the perforation site. But we need to upsize the left femoral sheath and we can already foresee some difficulties in engaging this anterior take off RCA with another GC again.

SION GW, loaded to the Corsair micro-catheter was used to wire the RCA. It could cross to PL branch quickly with brief deflation of the stent balloon. The stent balloon was re-inflated once the Corsair crossed the perforation segment (Figure 1). As the Sion GW may pass through stent strut, it is used for delivering a 2.25x15mm balloon for sealing the perforation when previous stent balloon was withdrawn (Figure 2). Finally, the cover stent was delivered via the original wire (Figure 3).

Two 30x38mm DES were deployed in the mid and proximal RCA respectively. Final shots showed good result at stented RCA, good flow to a small PL branch, no more contrast extravasation but loss of some PL branches (Movie 8, Movie 9) Bedside echo showed no significant pericardial effusion.

Conclusion
This case illustrate a safe method to deliver a cover stent to seal off perforation via a 8Fr (probably 7Fr feasible) GC with microcatheter and GW, instead of traditional 2GCs with pingpong technique.