Funny Coronary Arteriole Perforation Causes Tamponade Post-primary Percutaneous Coronary Intervention

An emergency transradial coronary angiography in a 68-year-old woman demonstrated sub-total occlusion of the proximal left anterior descending artery (LAD) (Figure 1A). Wiring was challenging because of a funny arteriole network arising from the proximal LAD (Figure 1B; Video 1), wherein the guidewire was entering inadvertently (Video 2). The lesion was finally crossed with a workhorse wire (Figure 1C). After pre-dilatation and implantation of a 2.5 x 30-mm zotarolimus-eluting stent, intracoronary tirofiban was administered due to slow flow. The final angiographic result was satisfactory (thrombolysis in myocardial infarction [TIMI] 3 flow) (Figure 1D). However, in the last cine-angiographic shots, a minor leak was noticed distally from one of the arterioles arising from the proximal LAD (Figure 1E; Video 3). A beside echocardiogram excluded pericardial effusion.

Forty-five minutes later, in the coronary care unit, the patient became tachycardic and hypotensive, and a repeat bedside echocardiogram revealed a large circumferential pericardial effusion. Urgent pericardiocentesis and removal of 200-cc hemorrhagic fluid improved the patient’s hemodynamics. She was transferred back to the catheterization laboratory. Right femoral artery access was used and an extra-backup (EBU) 4 was engaged to the left coronary system. LAD flow was intact, however, the leak was still visible (Figure 2A; Video 4). After wiring both the LAD and the left circumflex artery, prolonged inflations of a non-compliant balloon in the proximal LAD (Figure 2B) and implantation of a second zotarolimus-eluting stent (2.75 x 30 mm) in the LAD ostium, nicely overlapping the previous stent, failed to stop the leak (Figure 2C). A 3 x 20-mm PK Papyrus covered stent (BIOTRONIK AG) was then implanted in the proximal LAD to seal the perforated branch, and subsequently the active leak disappeared (Figure 2D; Video 5).  The patient had an uneventful recovery and was discharged 6 days later.

This case highlights the paramount importance of careful wiring for a safe percutaneous coronary intervention. Delivery of a covered stent in the main vessel to exclude the perforated branch, microcatheter-guided application of coils, local thrombin injection, or subcutaneous fat embolization are the treatment options for distal side branch perforation.

Affiliations and Disclosures

From the 1^st Cardiology Department, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece.

Disclosures: The authors report no financial relationships or conflicts of interest regarding the content herein.

Address for correspondence: Konstantinos C. Theodoropoulos, MD, MSc, 1^st Cardiology Department, AHEPA University Hospital, Aristotle University of Thessaloniki, Kiriakidi 1, Thessaloniki 546 36, Greece. Email: ktheod2005@hotmail.com; X: @ktheod2005