HKF

Mr. HKF, a 72 year old gentleman with underlying history of T2DM, hypertension, dyslipidaemia and ischemic heart disease. He has a history of acute inferior STEMI where PCI to PRCA was done 2 months earlier.He was admitted for a staged percutaneous coronary intervention (PCI) to a proximal left anterior descending (PLAD) artery calcified lesion.He was in CCS angina class I and in NYHA class II.

Blood work up was normal.Chest radiograph was also normal without congestion of the lung fields nor presence of cardiomegaly.Echocardiogram - LVEF 50 -55%, dilated LA, mild AS flow, mid to apical anterior/septal hypokinesia, no clots/no thrombus/no pericardial effussionECG - sinus rhythm and Q waves at the inferior leads, T inversion V5-6

Left main normalPLAD 80% stenosis with heavy surrounding calcificationsLCX normal RCA - not done
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1. Pre PCI loaded with T. clopidogrel 600mg stat and IA heparin 8000U.2. LCA engaged with EBU 3.0 6F.3. Wired down LAD with PT2 moderate support with Mogul microcatheter, however noted septal artery perforation at distal LAD.4. Immediately decided to perform balloon occlusion with Emerge Monorail 2.5x15 mm at 12 atm for about 15 mins while IV protamine reversal given. Perforation did not seal despite balloon occlusion. We did not have coil or covered stents at that point in time.5. Patient was haemodynamically stable throughout. Bedside echocardiogram did not show any pericardial effussion or septal haematoma.6. Procedure was halted and patient put on close monitoring with regular 30 mins bedside echocardiogram.7. Patient remained stable and symptom free with no evidence of any complications on echocardiogram. After two hours, we decided to proceed with PCI to LAD.8. IA heparin 5000U given, rewired with same wire and micocatheter. Exchange with Rota wire done.9. Rotablation with 1.5 burr at 180k RPM x3, exchanged back to PT2 wire and microcatheter removed.10. Predilatation done with Wolverine 3.0x15 mm at 16 atm.11. Stented with Promus Premiere 3.0x32 mm (DES) and postdilated with Emerge NC 3.25x15 mm upto 30 atm.12. Post procedure TIMI 3 flow with good results.13. Distal LAD Septal artery perforation stable throughout procedure, patient was well without other complications.


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Coronary artery perforation is an uncommon but potentially fatal complication of PCI. Pericardial tamponade or intramyocardium haematoma may be lethal if prompt actions are not taken. Balloon occlusion and reversal of anticoagulant are common methods to reduce the amount of bleeding. Here we describe a case of distal LAD septal artery perforation managed with balloon occlusion but failed. However patient did not develop any lethal complications as a result of the perforation. We postulate that the perforation had fortuitously drained into the ventricular chamber therefore we were able to complete the PCI with good results and without any compromise to patient safety.