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A 83-year-old male wasintroduced to our institute owing to the severely calcified coronary arteriesby general plane computed tomography (CT) and the history of cerebralinfarction with the stenosis of cervical artery. His diabetes history was morethan 20 years (HbA1c 7.4%), and other coronary risk factors were hyperlipidemia(TC 244 mg/dl, TG 189 mg/dl, HDL-C 57 mg/dl, and LDL 164 mg/dl), hypertension,and past smoking (Hb16.3 g/dl, Cre 0.87 mg/dl). 

InRCA (Figure 1), there was a diffuse stenosis from ostium to theproximal-portion (Lesion-1), and spot 90% stenosis in mid-portion (Lesion-2). Elective PCI was undergone by inserting a7Fr glidesheath via right radial artery, a guiding catheter (7Fr Champ1.5SH). Intravascular images showed the severelycalcification (Figure 2 for Lesion 1). Orbital atherectomy wasapplied along the diffuse calcifiedplaques. However, calcified plaques at proximal site was not fully modified(Figure 3)

Rotational atherectomy (burrsize 1.75mm) was undergone. Rotablator made superficial irregular lumensmooth (Figure 4). After 3-mm sized balloon dilations, XienceSkypoint (4x48 and 4x38 mm) were placedincluding ostium (Figure 5). Post-dilations using anon-compliant balloon (Raiden 4.5x15mm) were undergone. Immediately, coronaryperforations with multiple blowout flows classified as Ellis-classification type-3were occurred (Figure 6). Perforated lesion was suppressed by Raiden.

Raiden was exchanged to Ryusei,a perfusion balloon, inside Xience stent, suppressing the blowouts.Concurrently, a guiding catheter JR4 was nearly engaged to RCA via rightfemoral artery (Figure 7). Since activated clotting time was 154s, protaminewas not administered. Temporarily, Ryusei was deflating, and a GW (Sion blue)from the new system was crossed. Before removing Ryusei, oozing sites wereascertained, a polytetrafluoroethylene-covered stent (GraftMaster2.8x16mm) was prepared and rapidly deployed (Figure 8). After post-balloondilations by using NC Emerge (5x15mm) with 12 atmospheres (Figure 9),perforations were once ceased. IVUS images showed that GraftMaster tightlydilated inside Xience. However, along the perforated lesion, reference vessel diameterwas observed to be more than 8mm (Figure 10). The echocardiography did not showthe apparent pericardial effusion. A few minutes later, oozing flow recurred(Figure 11). Thus, GraftMaster was further dilated by using a 5.5mm-sized NCEmerge. The interval for these bailout proceduresfrom perforation to ascertain the cessation was 32 minutes. Finally, TIMI grade flow of 3 with good Xience dilationwas obtained in RCA (Figures 12). After the procedure, the maximum serum valueof CK was 750 (IU/dl) without accumulating pericardial effusion. He dischargedat the post-PCI days of 4.

We successful bailed out from the Ellisclassification type-3 acute perforations by alternatively inflating Ryusei, aperfusion balloon, prior to sealing a polytetrafluoroethylene-covered stent (“Ping-pong”technique) occurred immediately after rated pressure of 22 atmosphere dilationsusing a 4.5mm-sized non-compliant balloon inside Xience Skypoint Stent placedfor diffuse severely calcified proximal right coronary artery followed byorbital and rotational atherectomies.