Treatment for Type IV Coronary Perforation during Percutaneous Coronary Intervention

We report the case of a 61-year-od male, hospitalized for unstable angina. Coronary angiography showed a severe lesion in the middle third of the left anterior descending coronary artery. Percutaneous coronary intervention was performed with stent implantation. Coronary rupture was observed with contrast spilling to the left ventricle (type IV coronary perforation) immediately after balloon post-dilatation. After partial heparin reversal with protamine and prolonged balloon inflation at low pressure, coronary rupture was controlled, with a good final angiographic result. Subsequent echocardiography showed minimal pericardial effusion. Post-procedure clinical follow-up was satisfactory. DEsCrIPTOrs: Angioplasty. Stents. Rupture. Coronary vessels. 1 Interventionist cardiologist physician at the Interventional Cardiology Hemodynamic Service of Instituto de Cardiologia do Espírito Santo. Vitória, ES, Brazil. 2 Doctor. Interventionistl cardiologist physician at Instituto Dante Pazzanese de Cardiologia. São Paulo, SP, Brazil. 3 Interventionist cardiologist physician at CINECOR. Cuiabá, MT, Brazil. 4 Resident physician at the Invasive Cardiology Service of Instituto Dante Pazzanese de Cardiologia. São Paulo, SP, Brazil. 5 Doctor. Interventionist cardiologist physician at the Invasive Cardiology Service of Instituto Dante Pazzanese de Cardiologia. São Paulo, SP, Brazil. Correspondence to: Roberto Ramos Barbosa. Av. Marechal Campos, 1.579 – Santa Cecília – Vitória, ES, Brazil – CEP 29043-260 E-mail: [email protected] Received on: 8/22/2012 • Accepted on: 11/28/2012 rEsUMO Tratamento de Perfuração Coronária Tipo IV Durante Intervenção Coronária Percutânea Relatamos o caso de um paciente de 61 anos de idade, hospitalizado por angina instável. Cineangiocoronariografia demonstrou lesão obstrutiva grave no terço médio da artéria descendente anterior. Intervenção coronária percutânea foi realizada com implante de stent. Logo depois da pós-dilatação com cateter-balão, observou-se ruptura coronária, com extravasamento de contraste para o ventrículo esquerdo (perfuração coronária tipo IV). Após reversão parcial da heparina com protamina e insuflação prolongada do cateter-balão com baixa pressão, a ruptura coronária foi controlada, com bom resultado angiográfico final. Ecocardiografia realizada em seguida evidenciou derrame pericárdico mínimo. A evolução clínica foi satisfatória após o procedimento. DEsCrITOrEs: Angioplastia. Stents. Ruptura. Vasos coronários. Case Report C oronary perforation is a dreaded and potentially serious complication of percutaneous coronary interventions (PCIs), with high rates of morbidity and mortality.1 Perforation or frank rupture of coronary arteries are rare, occurring in 0.1% to 0.6% of patients undergoing PCI, reaching up to 3% of cases involving atheroablative techniques.1-5 The present study reports a case of coronary rupture (Ellis type IV perforation) draining into the left ventricle, successfully treated during the intervention. Case report Male patient, 61 years of age, smoker and hypertensive, who underwent coronary artery bypass graft (CABG) in 2002 (free radial artery graft to the left anterior descending artery, as a “Y” saphenous vein graft to the first marginal branch of the left circumflex artery) after an acute myocardial infarction without ST-segment elevation. He was admitted at another hospital in early November 2011, with a diagnosis of unstable angina. On that occasion, he remained under