Mr NR

A 46 year old Indian gentleman with a history of lacunar stroke in February 2022 and ischaemic heart disease. In April 2022 COROS showed 2VD and PCI to RCA was done. He is still symptomatic with angina on exertion. He was planned for a stage PCI to CTO LAD. Physical examination was unremarkable.

ECG showed he was in sinus rhythm with Q waves present over the inferior leads with poor R wave progression over chest leads. Echocardiography revealed a dilated left ventricle with EF 40% and several areas of regional wall motion abnormalities. 

Coronary angiogram done showed calcified 2 vessel disease with a dominant left system. Left main stem was smooth. Proximal LAD having 80% stenosis, CTO at mid LAD with collaterals from LCx. LCx was dominant with mild disease. RCA stent was patent with diffuse disease distally. 

EBU 3.5 6Fr engaged.Used antegrade wire escalation with Sion Blue, Fielder XT-R, XT -A and Gaia 2nd with Finecross microcatheter.Crossed with Gaia 2nd. Unable to advance Finecross beyond proximal cap.Attempted balloon dilatation with Alveo HP Balloon 1.0/10mm @ 14ATM and Ryurei 1.0/5mm @ 12 ATM but unable to dilate due to calcification.Guideplus extension used for extra support.Done Grenadoplasty with Ryurei 1.5/15mm@ 28ATM. Still unable to dilate lesion.With Finecross at proximal cap, wired down Rota Floppy wire.Done rotablation with 1.25mm burr @ 200k rpm 5 passes for 10-20 seconds.Rota floppy wire prolapsed during second run then rewired again. Upsized to 1.5mm burr @ 165k rpm 3 passes for 15-18 seconds.Exchanged to Sion Blue.Predilated LAD with Wolverine cutting balloon 2.5/15mm @ 18 ATM then with Sapphire NC 3.0/15mm @ 24 ATM.Stented mid LAD with Resolute Onyx 2.75/38mm @ 18 ATM.Stented ostial to prox LAD with Resolute Onyx 3.0/38mm @ 18 ATM.Post dilated proximal stent with Accuforce 3.5/15mm @ 20 ATM.Noted small perforation at mid LAD.Deployed cover stent PK Papyrus 2.5/20mm but had difficulty to deliver cover stent due to calcium. Postdilated LAD stent with Sapphire NC 2.5/15mm @ 24ATM.Persistent perforation noted.Done prolonged balloon inflation 3.0/15mm @ 180seconds then 300seconds then given reversal with protamine but perforation still leaking.Deployed 2nd cover stent PK Papyrus 3.0/20mm @ 10ATM.

No further leaking noted.No chest painTIMI 3 flow with good results.No dissection seen.No perforation seen.No significant ECG changes during procedure.Post procedure echocardiography noted minimal pericardial effusion0.3cm.Repeated reassessment scans did not show worsening.Coronary artery perforation is a life threatening complication ofPCI, therefore it is very important to be familiar with the techniques and equipmentthat are able to treat this complication.