Vol 80, No 10 (2022)
Clinical vignette
Published online: 2022-08-04

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When an interventional cardiologist needs an interventional radiologist: Efficient treating of coronary perforation

Adam Kern12, Robert Gil23, Grzegorz Wasilewski4, Krystian Bojko12, Sebastian Pawlak12, Grzegorz Poskrobko2, Ewa Andrasz2, Manas Atre5, Jacek Bil3
Pubmed: 35924993
Kardiol Pol 2022;80(10):1047-1048.

Abstract

Not available

CLINICAL VIGNETTE

When an interventional cardiologist needs an interventional radiologist: Efficient treatment of coronary perforation

Adam Kern12Robert Gil23Grzegorz Wasilewski4Krystian Bojko12Sebastian Pawlak12Grzegorz Poskrobko2Ewa Andrasz2Manas Atre5Jacek Bil3
1Department of Cardiology and Internal Medicine, University of Warmia and Mazury, Olsztyn, Poland
2Department of Cardiology, Regional Specialist Hospital in Olsztyn, Olsztyn, Poland
3Department of Invasive Cardiology, Centre of Postgraduate Medical Education, Warszawa, Poland
4Department of Radiology and Medical Imaging, Regional Specialist Hospital in Olsztyn, Olsztyn, Poland
5School of Medicine, Collegium Medicum, University of Warmia and Mazury, Olsztyn, Poland

Correspondence to:

Adam Kern, MD, PhD, FESC,

Department of Cardiology and Internal Medicine, University of Warmia and Mazury,

Żołnierska 18, 10–561 Olsztyn, Poland

phone: +48 89 538 63 49,

e-mail: adamkern@mail.com

Copyright by the Author(s), 2022

DOI: 10.33963/KP.a2022.0184

Received: April 14, 2022

Accepted: June 25, 2022

Early publication date: August 4, 2022

Coronary artery perforation is a life-threatening sequel complicating 0.2%–0.9% of percutaneous coronary interventions (PCI) [1]. Here, we present an example of fruitful cooperation between an interventional cardiologist and a radiologist in managing distal right coronary artery (RCA) perforation. A 76-year-old male with a history of dyslipidemia, type 2 diabetes mellitus, and prior PCI in the left circumflex artery was admitted for PCI in RCA with rotational atherectomy. The patient was on dual antiplatelet therapy (acetylsalicylic acid 75 mg and clopidogrel 75 mg). From the right radial approach, rotablation was performed with 1.5 mm and 1.75 mm burrs in the proximal and mid RCA segments (Figure 1AB).

Figure 1. A. Significant long stenosis in the proximal and medial RCA. B. A rotablation procedure (the red arrow showing the burr). C. Stent optimization with deep location of the distal guidewire (the arrow showing the distal end of the guidewire). D. Contrast extravasation (the red arrow). E. An example spiral coils used to close the perforation. F. The final view with coils (the red arrow) implanted in the posterolateral branch of the RCA
Abbreviation: RCA, right coronary artery

After successful rotablation, a working guidewire was advanced (Sion blue with a J tip, Asahi Intecc, Irvine, CA, US), and two sirolimus-eluting stents Prolim (Balton, Poland) were deployed in the mid (3.5 × 25 mm) and proximal (4.0 × 29 mm) segments. Stents were optimized with a non-compliant balloon catheter (4.0 × 12 mm) under intravascular ultrasound imaging (Figure 1C). However, at the final checking, the contrast extravasation next to one of the posterolateral branches was disclosed (Figure 1D; Supplementary material, Video S1). Despite three prolonged balloon inflations, the leakage was not stopped. Echocardiography showed no signs of cardiac tamponade; therefore, no protamine sulfate was administered. After consulting with an interventional radiologist, five spiral coils were used: three 1 mm/3 cm MicroPlex Hydrosoft 3D (MicroVention, Aliso Viejo, CA, US) and two 2 mm/3 cm + 2.5 mm/6 cm Axium Prime coils (Medtronic, Minneapolis, MN, US) (Figure 1E). The perforation was successfully closed with no excessive fluid in the pericardium (Figure 1F; Supplementary material, Video S2, and S3). The patient was discharged after two days on dual antiplatelet therapy.

In some cases, prolonged balloon inflation may lead to hemostasis, but if pericardial bleeding continues, definitive treatment may be needed (covered stents or cardiac surgery) [2]. However, covered stents are not feasible for small vessels. In such cases, embolization may play a part. In our patient, the radiologist used coils designed to close intracranial aneurysms. When introduced, their successive loops change direction, evenly distribute themselves within the vessel, and efficiently close the perforation. Moreover, poly (glycolide-co-L-lactide) or nylon microfilaments reduce the flow and accelerate thrombosis [3]. Such an approach allowed the patient to avoid open heart surgery and enabled quick discharge.

Supplementary material

Supplementary material is available at https://journals.viamedica.pl/kardiologia_polska.

Article information

Conflict of interest: None declared.

Funding: None.

Open access: This article is available in open access under Creative Common Attribution-Non-Commercial-No Derivatives 4.0 International (CC BY-NC-ND 4.0) license, allowing to download articles and share them with others as long as they credit the authors and the publisher, but without permission to change them in any way or use them commercially. For commercial use, please contact the journal office at kardiologiapolska@ptkardio.pl.

REFERENCES

  1. Tajti P, Burke MN, Karmpaliotis D, et al. Update in the percutaneous management of coronary chronic total occlusions. JACC Cardiovasc Interv. 2018; 11(7): 615625, doi: 10.1016/j.jcin.2017.10.052, indexed in Pubmed: 29550088.
  2. Bartuś J, Januszek R, Hudziak D, et al. Clinical outcomes following large vessel coronary artery perforation treated with covered stent implantation: comparison between polytetrafluoroethylene- and polyurethane-covered stents (CRACK-II registry). J Clin Med. 2021; 10(22), doi: 10.3390/jcm10225441, indexed in Pubmed: 34830722.
  3. Girdhar G, Read M, Sohn J, et al. In-vitro thrombogenicity assessment of polymer filament modified and native platinum embolic coils. J Neurol Sci. 2014; 339(1-2): 97101, doi: 10.1016/j.jns.2014.01.030, indexed in Pubmed: 24553053.



Polish Heart Journal (Kardiologia Polska)