A 55 years old woman with underlying diabetes and hypertension presented to our emergency department 16 hours after onset of typical chest pain. Patient was hemodynamically stable. 12-lead ECG showed sinus rhythm with ST segment elevation and pathological Q wave on anterior leads. 

Blood investigation : hemogloblin 13 g/dL, Urea 3.5 mmol/L,Troponin I 3240.8 ng/mL, Creatinine 36 mmol/L. Echocardiography showed reduced left ventricular systolic function (EF 30%), hypokinetic at anterior and apical wall, with normal valves.

Coronary angiogram showed right dominant, normal left main, total occlusion on the proximal part of left anterior descending artery. Normal circumflex, and mild disease in the proximal part of right coronary artery, total occlusion on the ostial posterior left ventricular artery.

Coronary angioplasty was performed via right radial access with guiding catheter Extra Back Up 3.5/6Fr. A Balance Middle Weight guidewire was unable to cross the lesion in the left anterior descending artery, however Pilot 50 guidewire was successfully passed into distal left anterior descending artery. Mid to proximal left anterior descending artery was predilated with Euphora non-compliant coronary balloon 2.5 x 15 mm at 14 atm. Two drug eluting stents ( Biofreedom Ultra 2.5 x 24 mm and Biofreedom Ultra 3.0 x 24mm) were deployed at proximal to mid left anterior descending artery. Post dilated it with Sapphire non-compliant coronary balloon 3.0 x 12 mm at 18 atm. At this point, noted there was a perforation in the distal left anterior descending artery. Inflated Sapphire non-compliant coronary balloon 2.0 x 15 mm at 4 atm at distal left anterior descending artery. Fine Cross micro catheter with Balance Middle Weight guidewire were passed to distal left anterior descending artery. Four pieces of 2-3 mm segments of absorbable sutures (Vicryl 3.0) were injected via Fine Cross micro catheter to distal left anterior descending artery, the procedure steps repeated another time. Post procedure showed residual perforation. Repeated echocardiography 6 hours after the procedure showed no pericardial effusion. Patient was discharged well the next day.

Coronary artery perforation is an uncommon but highly dangerous complication of PCI that can lead to significant mortality and morbidity if not promptly identified and treated. The most common cause of distal perforation is related to distal wire migration in a distal small caliber branch, hence constant attention to guidewire is very important. Absorbable suture embolization seems to be reasonable alternative strategy to control distal or small vessel coronary artery perforation.