Rare occurrence of simultaneous coronary artery perforation and intracoronary thrombus formation following angioplasty
A 67 years old male was admitted to the hospital for coronary angiography because of abnormal CT coronary angiogram in a screening test on March 3, 2011 (). His coronary risk factors included well controlled diabetes and current smoking. Echocardiography showed preserved left ventricular systolic function, no chamber enlargement and no valvular heart disease.\nTrans-radial coronary angiography (April 13, 2011) showed LCX had a long stenotic lesion up to 80% at mid portion (). The left main (LM), left anterior descending artery (LAD), and right coronary arteries were practically free of disease. PCI was attempted to mid LCX lesion. Procedure PCI was done with XB 3.5 guiding catheter after being anticoagulated with weight-based heparin. A BMW guidewire was advanced into the distal LCX and another BMW guidewire in the side branch of the LCX. After balloon pre-dilatation, a sirolimus-eluting stent 2.75 × 24 mm (EXCEL, JW Medical System, Weihai, China) was deployed at 12 atm. Shortly after post dilatation was done with stent's balloon to 11 atm, the patient became haemodynamically compromised and cardiac arrest. Angiography confirmed the presence of Ellis grade 3 coronary perforation at the distal part of the stent with free flow of contrast into the pericardial space (). Emergent echocardiography also confirmed a large pericardial effusion with cardiac tamponade. The effect of heparin was reversed with 30 mg of intravenous Protamine. Nasotracheal intubation and pericardiocentesis were performed to restore hemodynamic stability. The stent's balloon was reinflated immediately at the site of the perforation to 5 atm (), which was unsuccessful. Leakage continued after 30 min of balloon inflation, for no suitable cover stents available, the decision was made to place microcoils to close the perforation by a neuron-intervention physician. After 7 Microplex coils (Platinum Detachable Embolization Coils, MicroVention, Aliso Viejo, CA, USA) were placed from the distal LCX to the perforation site via microcatheter, the perforation was embolized with no extravasations of contrast into the pericardial space (). Repeated angiographic pictures showed the presence of subtotal occluded acute thrombus in the left main artery and in-stent macrothromus in LCX (), aspiration thrombectomy was attempted (), followed by Tirofiban Hydrochloride anticoagulation. Thereafter, the patient remained hemodynamically stable after transferred to the coronary care unit. ECG confirmed the posterior and lateral wall myocardial infarction and the maximum troponin I level was 15.97 ng/mL. A Pigtail drainage catheter was left in the pericardial space for 2 days, and the nasotracheal tube was successfully removed 3 days later. Fondaparinux sodium (ARIXTRA) was injected subcutaneously for 7 days without any event. He was discharged two weeks later and had no effort angina and cardiac dysfunction with more than one year follow-up.