SS–09 Both the Cause and the Solution: GuidewireInduced Distal Coronary Perforation

Abstract

Introduction and Aim: A patient with a history of hypertension, smoking, and a family history of coronary artery disease presented via emergency medical services due to severe chest pain radiating to the left axilla that began today. The patient had no prior history of coronary artery disease, and current medications included losartan 40/12.5 mg and nebivolol 5 mg. The baseline ECG showed sinus rhythm with ST-segment elevation in the inferior leads and T-wave inversions in the anterior leads. Echocardiography revealed an EF of 55%, inferior wall hypokinesia, an interventricular septum of 14 mm, a left atrium of 42 mm, and mild mitral and aortic regurgitation; the inferior vena cava was collapsible, and no pericardial effusion was present. Based on the clinical, electrocardiographic, and echocardiographic findings, acute inferior myocardial infarction was diagnosed, and the patient was immediately transferred to the catheterization laboratory for emergency coronary angiography.

Methods: Coronary angiography demonstrated a normal left main coronary artery (LM). The left anterior descending (LAD) artery showed a 30% stenosis after D1 and a 40% stenosis in the distal segment. The left circumflex (LCX) artery showed a 40% stenosis in the proximal segment and a 60–70% long sequential stenosis in the mid segment. A critical 99% stenosis was identified in the right posterior lateral (RPL) branch of the right coronary artery (RCA). Based on clinical and imaging findings, the RCA lesion was considered the culprit lesion. Using a right radial approach, the RCA was cannulated with a 6F JR4 guide catheter. The RPL and posterior descending artery (PDA) were crossed using Anyreach wires. Percutaneous transluminal coronary angioplasty (PTCA) was performed on the RCA-RPL lesion using a 3.0×12 mm non-compliant (NC) balloon at 12 atm, followed by the implantation of a 3.5×19 mm drug-eluting stent (DES). The stent was post-dilated with a 3.75×12 mm NC balloon.

Results: During the procedure, a guidewire-induced coronary perforation/ rupture occurred in the distal branch of the PDA. Balloon tamponade was applied in the proximal PDA using 2.0×20 mm and 2.0×12 mm balloons for 2.5 minutes; however, the extravasation persisted. A Finecross microcatheter was advanced into the perforated distal branch, and a severed Pilot 50 wire was intentionally left in the perforated distal vessel through the microcatheter. The perforated distal branch was successfully occluded via controlled thrombosis. Follow-up echocardiography performed during the procedure showed no pericardial effusion. As the procedure continued after completing the RCA stent post-dilation, stenosis due to plaque shift was observed at the PDA ostium. PTCA was performed on the PDA ostium using a 2.5×15 mm NC balloon, restoring full patency.

Conclusion: In conclusion, the 99% critical lesion in the RCA-RPL region was successfully treated with PCI and stent implantation in a patient presenting with acute inferior myocardial infarction. The procedure was complicated by a guidewire-induced perforation in the distal PDA branch, which was managed via controlled occlusion of the distal vessel, with follow-up echocardiography confirming the absence of pericardial effusion. Additionally, acute PDA ostial plaque shift during the procedure was successfully treated with balloon angioplasty. Beyond the culprit RCA lesion, elective stage PCI or close medical follow-up was planned for the 60–70% long-segment LCX mid-vessel stenosis.