A 67-year-old woman with a medical history of dyslipidemia was admitted to our center with an inferior ST-elevation myocardial infarction (STEMI). A coronary angiogram was performed via right radial access, revealing the left coronary system without severe stenoses. The right coronary artery (RCA) was then engaged with a 6 Fr JR 4.0 guide catheter, which revealed proximal occlusion of the vessel. Wiring was challenging, and eventually a workhorse guidewire (Cougar XT, Medtronic, MN, USA) with the support of a 1.5 × 20 mm over-the-wire (OTW) balloon seemed to have crossed the lesion into the true lumen (Figure 1 A). However, antegrade flow was not restored and predilatations were performed at the point of the occlusion with the same balloon and with a 2.0 × 20 mm semi-compliant balloon. After the inflations, subsequent contrast injections revealed that the guidewire was inside the pericardial space, having perforated the RCA, which resulted in an Ellis III coronary perforation (Figure 1 B). Prolonged balloon inflations were performed proximal to the site of the perforation to stop the bleeding and prevent cardiac tamponade, but without success (Figure 1 C). The patient gradually became hemodynamically unstable and a large circumferential pericardial effusion was depicted with a bedside echocardiogram. Urgent pericardiocentesis was performed, autologous blood transfusion from the pericardium to the right femoral vein was achieved through a central venous catheter, and a right femoral arterial access was secured. A second 7 Fr JR 4.0 guide catheter was then advanced from the right femoral artery while a semi-compliant balloon from the 6 Fr catheter was inflated in the proximal RCA to prevent further bleeding (dual catheter/ping-pong technique) (Figure 1 D). The semi-compliant balloon was then transiently deflated and a new workhorse guidewire (Cougar XT, Medtronic, MN, USA) was successfully advanced via the second catheter across the perforation site into the true lumen, and finally crossed the occlusion (Figure 1 E). The first guidewire was removed and subsequent predilatations at the RCA occlusion point with a 3.0 × 30 mm semi-compliant balloon limited the blood extravasation. After the deployment of a 3.0 × 20 mm PK Papyrus covered stent (BIOTRONIK AG) at the point of artery perforation, the leak into the pericardium disappeared (Figure 1 F). A 3.5 × 15 mm zotarolimus-eluting stent (Resolute Integrity, Medtronic, Minneapolis, USA) was also implanted proximally, nicely overlapping the covered stent. The perforation was successfully sealed and the final angiographic result was satisfactory, with thrombolysis in myocardial infarction (TIMI) 3 flow in the RCA. Six months later the patient remained asymptomatic and stable.
Figure 1
A – Proximal occlusion of the right coronary artery (RCA) (white arrow). A workhorse guidewire (blue arrow) crossed the lesion (as we falsely believed) with the support of an over-the-wire balloon (red arrow). B – After predilatations at the point of the occlusion, contrast injections revealed that the guidewire was inside the pericardial space having perforated the RCA, which resulted in an Ellis III coronary perforation (white arrow). C – Proximal balloon inflations were performed (white arrow), but without success. Cardiac tamponade was developed from the large circumferential pericardial effusion (red arrows). D – A 7 Fr guide catheter (white arrow) was advanced to the ostium of the RCA while a semi-compliant balloon (red arrow) from the 6 Fr guide catheter was inflated to prevent further bleeding into the pericardium (dual catheter/ping-pong technique). Urgent pericardiocentesis was performed to stabilize the patient (blue arrow: catheter of the pericardiocentesis). E – The semi-compliant balloon was transiently deflated and a new workhorse guidewire from the 7 Fr catheter crossed the occlusion (white arrow). F – After the implantation of a 3.0 × 20 mm PK Papyrus covered stent (BIOTRONIK AG) in the perforation entry point, the leak into the pericardium disappeared (white arrow)
This case highlights the paramount importance of careful wiring during percutaneous coronary interventions (PCI) [1, 2]. Orthogonal views are essential to assess the guidewire movement, especially in cases of total occlusions, before advancing further equipment. Alternatively, a small amount of contrast can be applied through a microcatheter to confirm the guidewire position into the true lumen. In cases of uncertainty, balloon predilatations should not be performed. Urgent pericardiocentesis and autologous blood transfusion is a life-saving first step if cardiac tamponade develops. The dual guide catheter (ping-pong) technique represents an effective way to seal perforations with better mortality rates compared to single catheter use [3]. Although the incidence of coronary perforation remains low (0.39%) [4], interventional cardiologists should always be alerted to deal with this fatal complication.
