TCB

76-year-old gentleman with hypertension, dyslipidemia and chronic kidney disease stage 3b, had history of coronary angioplasty to right coronary artery (Cypher 3.5x28 mm) and left anterior descending artery (LAD) in 2007 (Cypher 3.5x18 mm and 2.75x18mm stent) and 2010 (Promus 2.75x38 mm and 2.5x38 mm stent from mid-distal LAD). He presented with NSTEMI and was referred for early intervention. Clinical examination was unremarkable. 

Total white 8.2x10⁹/L, Hemoglobin 11.2 g/dL, Platelet 498x10⁹/LUrea 13.3 mmol/L, Na 139 mmol/L, K 4.4 mmol/L, Creatinine 193 umol/LTroponin T 283 pg/mlT. Chol 2.5 mmol/L, TG 1.6 mmol/L, LDL 1.0 mmol/L, HDL 0.8 mmol/LEchocardiogram showed ejection fraction 25% with moderate mitral regurgitation. There was severe hypokinesia at LAD territory. 

Coronary angiogram showed normal left main, mild disease at left circumflex, severe in-stent restenosis with total occlusion at mid segment (Waksman ISR Classification Type IV) and patent right coronary artery stent with collateral to LAD. 
LAD.avi
LCX.avi
RCA.avi

Coronary angioplasty was performed via right femoral access with guiding catheter Extra Back Up 3.5 / 6Fr and antegrade wire escalation approach. Workhorse wire Sion Blue was escalated to Fielder XTA and it managed to cross the lesion to distal LAD. Sion Blue was placed in Diagonal 1 for stabilization of guiding catheter and LAD was predilated with semi-compliant balloon 1.0x10 mm, 2.0x15 mm and 2.5x15 mm. Further preparation was performed with Scoring Balloon 2.5x15 and 3.25x13 mm at high pressure. Peri-stent dissection was noted at the distal LAD as well as staining of contrast at the end of Diagonal 1 consistent with Ellis Type V distal perforation. Patient remained hemodynamically stable and decided to be deployed a drug-eluting stent 2.25x15 mm at distal LAD overlapped with previous stent. Subsequently, autologous subcutaneous fat embolization via rapid transit microcatheter was attempted, but it failed to seal the perforation. Different strategy with coil complex 4 mm x 4 mm were chosen and it successfully terminated the leakage. Finally in-stent restenosis was treated with two drug coated balloon at 2.75x40 mm and 3.5x35 mm. Serial echocardiogram showed minimal pericardial effusion (0.5 cm) and he was discharged home. 
Ellis Type V perforation.avi
Coiling 2.avi
Final result.avi

Distal artery perforation is possible with hydrophilic workhorse wire. There were various ways to intervene the distal artery perforation i.e. microcoil, gelform, autologous clotted blood, fat embolisation or thrombin, subjected to its availability in center. In this case, we demonstrated two strategies to terminate the leakage by using microcoil.