Two Simultaneous Complications in a Tortuous, Calcified Right Coronary Artery
Dr. Lai Sze-wah
Background
A 61-yr-old male, with known DM and ESRF on CAPD, presented with exertional angina. Echocardiogram showed normal LV systolic function and mild hypokinesia over posterior wall. Coronary angiogram showed severe pLAD/D1 stenosis and heavily calcified RCA with critical proximal to mid segment stenosis, dRCA was tortuous with diffuse disease (Movie 1, Movie 2). PCI to LAD was performed smoothly and eventfully. Stage PCI to RCA was planned.
Procedure
7Fr MAC 3.75 guiding was used. Rotational atherectomy with 1.5mm burr to the calcified RCA lesion was planned. Sion guidewire with Finecross microcatheter was wired down to dRCA and then it was then exchanged with Rota-floppy wire. However, rotablation was complicated by perforation at dRCA, resulting in type III perforation. RCA was immediately rewired with with Grand Slam guidewire and 2.5mm balloon was inflated at pRCA to occlude the flow (Movie 4).
Patient ran into PEA. Immediate resuscitation and pericardioventesis were performed. IABP was inserted and mechanical ventilation was given.
Finecross microcatheter was advanced along the rota-floppy wire but the distal tip of the rotawire was broken and dislodged at rPAV branch (Movie 5). To seal off the perforation, cover stent was delivered to the perforation site with much difficulty, despite using Guideliner. It was finally deployed. Two other DES were deployed at mid and proximal RCA. Although the perforation was successfully sealed, the PDA was lost due to its ostium being covered by the cover stent (Movie 6). Attempt to puncture the cover stent with Conquest Pro GW was unsuccessful.
To retrieve the broken rotawire at rPAV, microsnare (EV3 Microsnare kit 4mm) was used and the broken segment was successfully retrieved (Movie 7). Final angiogram showed satisfactory result though the PDA was lost. (Movie 8)
Discussion
Incidence of perforation is about 0.7% in multicenter registry. Passing the rotablator too distally and in angulated vessels increase the risk of perforation. Minimizing guidewire bias by proper co-axial alignment of guiding catheter and guidewire placement should be done before starting rotablation.