Iatrogenic dissection of Trans-Radial CTO PCI of LCX- Sequential and prolong ballooning seal the perforation after stenting.

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By: Shams Munwar, MRCP(UK), D.Card (London), FRCP(Edin); AHM Waliul Islam, MBBS, PhD., FACC, FSCAI, FAPSIC

Submitted: 07/07/2012

Operator(s):
Shams Munwar, MRCP(UK), D.Card (London), FRCP(Edin); AHM Waliul Islam, MBBS, PhD., FACC, FSCAI, FAPSIC

Affiliation(s):
Dept of Invasive and Interventional Cardiology, Apollo Hospitals Dhaka.

Facility/Institution
Apollo Heart Center of Apollo Hospitals Dhaka, Bangladesh

Clinical History
Mr. IA/77 yr old Bangladeshi gentleman, admitted for CAG for his ongoing chest pain on exertion. His CAD risk factors were HTN, Dyslipidemia. H/o PPI on 16/2/2009 for CHB. Her admission BP was 130/80mmHg, Heart: S1+2 N. CAG was planned and carried out. CAG revealed CTO lesion of mid LCX. He was recommended for PCI to LCX.

Angiography
LM: Normal LAD: good size vessel. 30-40% plaque in proximal LAD. Rest of the LAD ok. LCX: good size artery. 99% -100% calcific plaque at mid LCX. Distal circ and OM ok (Fig 1) RCA: Good size artery. 30% plaque at crux. PDA and PLB ok (Fig 2).

Procedure
LCA was engaged with the EBU -3.5 (6F). Galeo floppy wire was tried to cross the lesion. Then an Intermediate wire was tried to cross the lesion (Fig 3). Ballooning was done with a 2.0 x 10mm Saphire balloon (Fig 4, Fig 5). Cine shows it was in falls lumen (fig 6). Wire exchanged to run-through floppy and re-cross the lesion into true lumen. Ballooning done (Fig 7 , Fig 8 and Fig 9)). Stent Promus Element 3.5 x 16 mm deployed and cine shows dye staining indicates perforation (Fig 10, Fig 11). Heparin reversal done. Echo shows trivial pericardial effusion. Sequential balloon stasis done in the perforation site for 30 min successively each for 5,10,15 and 30 mins.( Fig 12, Fig 13). Finally leakage stopped. Final cine shows no more oozing and TIMI III distal run off Fig 14, 15)

Conclusion(s)/Result(s)
CTO PCI carries a risk of perforation. Individual operator skill and available hardwire can suffice to overcome the situation. By prolong sequential ballooning could be an alternative instead of Covered stent. Moreover, if the patient remain stable both haemodynamically and clinically, then no need to rush. Just heparin reversal, Echo screening and prolong ballooning can often seal the perforation.

Comment(s)/Lesson(s)
Interventionist expertise and well-timed decision in handling the complication can make the procedure successful. Incase of non-availability of covered stent, successive and sequential prolong ballooning can seal the perforation

Conflict(s) of Interest
None

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