SOL ÖN

Türk Kareliyol Dem Arş 2002:30: 127-129

Successful Management with Coated Stent of Osteal Perforation of Left Anteri or Descending Artery due to Laser Angioplasty

Hüseyin YILMAZ, M.D, Oktay SANCA KTAR,M.D, İbrahim DEMİR,M.D, Filiz ERSELTÜZÜNER, M.D.

Akdeniz University Medical Faculty, Antalya- Turkey

SOL ÖN

İNEN

KORO NER

ARTERİN

LAZER AN JİYOPLASTİSİNE BAGLI OSTİUM PERFO- RASYONUNUN KAPLI STENT

İLETEDAVİSİ

ÖZET

Koroner arter pelforasyonu perkutanöz koroner

girişimin

nadir bir komplikasyonudur. Yazmmda akut anterior mi- yokard enfartiislii bir olguda pirimer anjiyoplastide exi- mer laser

uygulanması

sonucunda sol ön inen arter osti- yumunda pelforasyon olgusunu bildirdik. Pelforasyon bölgesi

PTFE-kaplı

stent ile

kapatıldi.

Perikm·d tampona-

dı

perikarda

yerleştirilen

6

frenc/ı slıeatlı

içinden ilerieti- fen pig-tail kateter/e

boşaltıldı

ve

açık

kalp cerrahisinde pelforasyon bölgesi pirimer

onarılarak

sol internal

manı­

marian arter sol ön inen arter anastomozu uygulandi.

Tiirk Kareliyol Dem Arş 2002; 30: 127-129

Anahtar kelime/er: Koroner arter pe1forasyonu, stent, koroner anjiyoplasti, kalp

tamponadı,

akw miyokard en- {arktiisii.

Coronary perforation is a rare and life threatening complication of pe rcutaneous coronary intervention.

Reported ineidence var i es between O, 1-3,0% within seve ral interventional methods

(1-4).

There is canco- mitant in crease with the use of new atheroablativ e d ev ices that cut, vaporize, or drill the vessel wall (5).

Hol mes e t al (6). reported that coronary perforation d uring excimer lase r angioplasty as 1.3% and 5.6%

fatal

outcoıne

withi n the perforation group. Altho- ugh, non-surgical treatment of this life threatening co mplication is possible conservatively w ith

rep

ea- ted angioplasty, bare stent, and coated stent

(7-9)

s ur- gical treatment of coronary perforation is necessary in 37 to 63% of the cases

(5,6,10).

We report a case of successful closure of an osteal perforation of left anterior d escend ing artery with polytetrafluoroethylene (PTFE)-covered stent during excimer laser angioplasty.

Reccived: 27'" August, revision accepted 4'" Dcccınber 2001 Corrospending Address: Hüseyin Yılmaz, Akdeniz University Medical Faculty, Department of Cardiology, 07070 Antalya, Turkey Plıone: +90-242-227 43 31 Fax: +90-533-982 46 45 E-Mail: drlı[email protected]ll.com.tr

CASEREPORT

A 64-year old

maıe

patient was admitted to our outpat ient clinic due to continuing exercise induced chest pain fo r o f

ı hOLıı·'s

duration. ECG recordings showed

pathoıogic

Q waves in V 1-3 w ith persistent ST segment

eıevation. Plıysicaı

examination showeel no

abnormaıity.

Patient was eliagnosed as having acute anterior

ınyocardiaı

infarction.

He subseque ntly underwent coronary angiography and left venrieulography. Coronary angiography revealed total occlusion of LAD at the !eve! of the ostium with T

IMI-O

coronary flow. Left circumflex and right coronary artery were normal (Figure-1 A). Left ventriculography revealed hypok inesis of anterolateral and apical

segınents.

Because of continuing chest pain and concomitant ST segment elevation,

priınary

angioplasty was planned.

The

ostiuın

of the LMCA was catheterized w ith 7F 3,5 XB guiding catheter and 0,0 14-inch

wisdoın

guide-wire ad- vanced through the occlusion to the distal part of LAD.

Afterward, 3.0 20 mm balloon dilatation catheter (Aclante Bostan Scientific Scimed, USA) was advanced over the guide-wire into the occlusive lesion without any difficulty anel inflatecl at 8

atın

for 30 seconds. It

resulıed

with TIMI- I antegrad flow anel the lesion was fu ll of thrombus (Figu- r e-lB). For elebulking of the osteal plaque material and to get rid of the

throınbus, exciıner

laser angioplasty (2,0

ının,

Vitesse-Cas Concentric, Spectranetics, Colorado.

USA) was applied to the lesion. After fi rst pass through

the lesion with

ıaser

cathcte r, the patient sueldcnly

becaıne symptonıatic

w ith the

coınplaiıııs

of faintness and diapho-

resis. Injection of radioopaque into the coronary showeel

ınassive

opaeification of the pericardium through a perfo-

ration of the osteal LAD (Figure-lB). Within seconds pa-

tient lost his consciousncss with concomitant respirato ry

arrest. Urgently we introduced second guide-wire into left

circumflex artery and decided to seal LAD osteal perfora-

tion w ith PTFE-covered 3.5

ı

8

ının

Jo-stent (coronary

stent graft,

Joıned Inıplantate

GMH, Rangendingen, Ger-

ınany)

(Figure-l C). W e placed

proxiınal

part of the stent

in the LMCA and distal part in the LCX artery and

ıhcn

inflatecl at 17

atın

for 20 see. Subsequent

angiograıns

d id

not show any Icakage of the d ye and distal blooel flow w as

well maintained (Figure-lD). While

iınplanting

the stent,

the patient was entubated and pericardio sentesis was per-

formed successfu lly. A 6 French pigtail advanced into the

pericarelium via arterial sheath. About 1 li ter of blood was

decoınpressed

and reinjected to the patient via venous ac-

cess. After decompressing the pericardial tamponade blo-

ad press u re increased stead ily up to ll 0/70 mmHg. Acti-

vated coagulation ti me was 335 seconds. Echocarcliog-

J Illi\ 1\(/IUlJUl Ut:lll rll~ ~VV4, .JV. 141 ~ıL)'

raphic study at

the cathete

r

laboratory revealed persistent

pericardial blood of

abouı

6-1 O mm.

Bccausc of the evol- ving

myocardial infaretion

and cardi

ac

ıaıııponade,

we

ur-

gently

referred the patie

nt to

enıergent

cardiac surgery.

At opcn-heart surgery there was stili

ıninute

bleeding from the site of pe rforat ion,

which was

repaired primarily, and UMA to LAD by-pass grafting was

perforıned.

The el inical course was excelle nt afte r cardiac surgery and after l

2

day s patient d

ischa

rged

on a

nt

iplatelet treatment with ticlodipine anel

aspirin.

DISCUSSION

Coronary perfo ration is a rare and life-threatening complica tion of a percutaneous coronary interventi - on, and the ineidence of perforali on is O, I to 3,0%

among lesions treated with various interventiona l techniques

(1-4).

Coro nary perforation may lead to cardiac tamponade and death

C ı ıl.

W ith the use of

new atheroabl ative devices the ine idence of co ro- nary perforation is low

(II)

compareel to coronary ang ioplasty, but device specific risks have not been defined yet. Coronary perfo ration ca n be caused by guide-wire and oversizeel balloon that mismarch to coronary artery

diaıneter (t2).

Other risk factors are calcified, tortuous and

noncoınpliant

arteries (t3).

Conse rvat ive transeatbeter therapy of the coronary perforalien incl udes prolonged balloon inflatio n with either the angiopl asty balloon or a perfusion cathete r at the site of the perforation. However, balloon dila- tation carheter blocks the blood flow distal to the inf- lation si te and produce ischemia. On the other hand, perfusion balloons seals the defect, permit distal ves- sel perfusion, and reduces the ische mia during pro- longed infl a tion . Polytetrafl uoroethylene-covcred stents

(14-16),

and autologo us ve in g raft-coverecl

Figure ı. Cororıary angiograın during cxciıner lascr angioplasty. A, baseline angiography, total occlusion or lerı antcrior dcsccrıding artcry.

B, Coronary rupturc and Icakage of contrast at the lcvcl of LAD ostiuın. C, Deployenıent of PTFE-covered st en ı. D, Firıal res u lt arter PTFE- coated sıcnl with no further Icakage.

128

H. Yılmaz el al.: M anagemeni willı Co(({ed S1e111 ofOsleal Peljor(l{ion ofLejl Amerior Descending Ar1ery due 10 Laser Angioplcwy

stents may be successful as reported in previously in case o f the failure with prolonged balloon inflation , bare s ten ts,

(7-ıoı.

High ra te of s uccess have been re- port ed with polytetrafluoroethylene covered-stents

(14-16).

AVG-coated stents cou ld be difficult to hand- le in emergencies. Other devices have been used in limited numbe r of cases with coronary artery perfo- ration s uch as micro-coil emb olization Cl7l.

There was no time to prepare A VG-sten t in our case because of massive leakage and acute detoriation of the patient, and bare stent would be ineffective beca- use of the location of the perforation. We inflated and sealed the perforation successfully with PTFE- covered Jo-stent.

Recently covered stents have been an alternative the- rapy to

eınergency

cardi ac s urgery in selected pati- ents with coronary perforation. Coated s tents, avoi- ding blood leakage between stent

sıruts,

may be an alternativ e to emergency s urgery especially in case of rapid detoriation and s hould be the choice of therapy in case of coronary perforation.

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