A 59 year old gentleman with hypertension, dyslipidaemia, coronary artery disease and obesity. He had history of PCI to LAD and RCA in 2004 and 2010. He presented with recurrent unstable angina. Therefore, coronary angiogram was performed.  

ECG: T inversion anterior leads
Troponin T: normal

Left Main Stem : Normal Left Anterior Descending : In-Stent Restenosis followed by Chronic Total Occlusion, short segment, retrograde to Right Coronary Artery Left Circumflex Artery : Mild distal disease(co-dominant) Intermediate : Moderate to severe proximal disease Right Coronary Artery : Diffuse proximal to mid Right Coronary Artery, followed by total In-Stent Restenosis distal Right Coronary Artery 

The procedure commenced with EBU 3.5/6F catheter and CTO wire with microcatheter. Managed to cross the lesion and changed to workhorse wire. Proximal LAD ISR predilated with SC balloon 2.0/15mm. CTO at mid segment predilated with same balloon. However, noted perforation at mid LAD after predilatation. We used the same balloon to tamponade the perforation and attempted to wire down distal LAD with another wire but failed. Right femoral puncture was performed and another EBU3.5/6F was used. The ping pong technique was used in which another workhorse wire to distal LAD when tamponade balloon was deflated.  However, the covered stent was unable to cross the proximal LAD. Proximal segment was then predilated with NC 2.5/15mm, yet still unable to advance the covered stent. Subsequently, guide extension GuidePlus II was used and managed to advance covered stent 2.5/20mm. Tamponade balloon was then removed and covered stent deployed at perforation site. We proceeded with drug coated balloon angioplasty to proximal-mid LAD using DCB 3.5/20mm. Patient was stable and bedside echo revealed minimal pericardial effusion only

Coronary artery perforation is rare but potentially lethal complication. Early recognition and immediate balloon occlusion are crucial in preventing cardiac tamponade and haemodynamic compromise. Double catheter guide technique (ping pong) allowed controlled delivery of covered stents to perforation site. It ensures uninterrupted balloon occlusion of perforated site and smooth delivery of bulky covered stents.