57 male, h/o CAD - s/p PTCA to om1 (2014) presented with new onset angina at rest and sob - NYHA FC iii, diagnosed as ACS - NSTEMI in SR with good LV function. S/p CAG showed DVD (RCA & om) with 90% ISR of om stent. Initially, PCI to LCX-om1 was done with 3.0 x 32 mm des. Following which PCI to RCA done with 2 stents, 2.75 x 48mm des deployed in mid RCA and 3.0 x 23 mm des deployed in prox RCA overlapping mid RCA stent. After post dilation there was a grade 4 perforation in proximal RCA. The perforation was effectively managed by the ping pong technique.
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After grade 4 perforation, immediately balloon tamponade was done with stent balloon. Pericardiocentesis done with pig tail catheter placed in the pericardial space.
RCA was engaged from the femoral route with ping-pong guide technique and a covered stent 2.8 x 26mm was deployed in the proximal RCA covering the perforation.
Covered stent was post dilated with 3 x 12 ballon.
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After covered stent deployment using ping pong guide technique, hemodynamics were stabilized and angiogram confirmed sealing the perforation with TIMI iii flow in distal RCA.
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To conclude: we had a grade 4 perforation in proximal RCA, after balloon tamponade with the stent balloon, and pericardiocentesis, using ping pong guide technique through the right femoral access, we have immediately secured and sealed the perforation with covered stent and hemodynamics were stabilized with TIMI iii flow in distal RCA.