A 75-year-old woman presented with chest pain. She had a history of diabetes, dyslipidemia, and hypertension and was admitted for PCI of the left anterior descending artery (LAD). Figure 1 presents the case timeline. Chest pain was present for 7 years but was aggravated for 1 month after activity and was accompanied by dyspnea. No radiating pain occurred. There was no fever, dyspnea, palpitation, upright breathing, or syncope. Coronary angiography (CAG) 1 month before admission revealed insignificant atherosclerotic plaques in the right coronary artery but severe stenosis in both the left circumflex artery (LCX) and LAD. She underwent elective stent deployment in the left LCX at that time. Physical examination was unremarkable, except for hypertension (145/80 mmHg). The patient's complete blood count, biochemical analyses (including the myocardial enzymes), and coagulation tests were normal. An electrocardiogram showed sinus rhythm and nonspecific ST-T segment changes. Transthoracic echocardiography images revealed decreased left ventricular diastolic function.
Elective PCI was performed with a 6 Fr guiding catheter and an Asahi Sion guidewire via a trans-radial sheath. After wiring, pre-dilatation was performed with a 2.0 x 20 mm compliant balloon at 10 atm and a 2.5 x 10 mm cutting balloon. Two drug-eluting stents of 2.75 x 33 mm and 3.0 x 18 mm were deployed from the mid to proximal segment of LAD. The overlapping stents were post-dilated at 18 atm with a 2.75 x 10 mm noncompliant balloon catheter. CAG showed a CP at the stent of the mid-LAD (Figure 2a). The patient complained of severe chest pain, and a drop in blood pressure and heart rate was noted a few minutes later, followed by Adams-Stokes syndrome. External cardiac massage was started, and the patient was intubated and ventilated. Large pericardial effusion restricting heartbeat was visualized by fluoroscopy during cardiopulmonary resuscitation (CPR). Repeat angiography confirmed an Ellis type III CP at the stent implantation site (Figure 2b). Pericardiocentesis was performed successfully, and about 400 ml of blood was suctioned and re-injected through a femoral vein. The patient's hemodynamics were stably restored, and the whole CRP lasted 15 minutes. The guidewire system dislocated during the rescue process, caused by the patient's unconscious agitation. It took some time to reset the guiding catheter and advance the guidewire. Repeat CAG showed a diffusive thrombus in the mid ostium of the LAD without contrast extravasation, indicating that the perforation had healed (Figure 2c). Considering the benefit of the anterior descending branch, we aspirated the thrombus to avoid further occlusion. After aspiration, the anterior descending artery recovered patency, but contrast agent extravasation occurred (Figure 2d). Prolonged balloon inflation was performed. A 2.75 x 12 mm balloon was inserted to tamponade the vessel at 6 atm on the leakage port. A contrast agent was administered to confirm that the blood vessel had been fully blocked (Figure 2e). The balloon was dilated for 15 minutes, with a 2-minute break for blood perfusion. Contrast agent extravasation persisted at the perforation site on the angiogram after 3 balloon occlusions (Figure 2f). We dragged the balloon to the proximal site of the CP and inflated it again to block the blood flow (Figure 2g). Simultaneously, we prepared a membrane-covered stent to standby. The balloon was dilated for about 10 minutes and subsequently deflated. Repeat angiography showed no contrast agent extravasation and no obvious thrombosis reformed in the stent (Figure 2h). The operation was completed, and the patient was sent to the intensive care unit (ICU) for monitoring and treatment.
The patient suffered from cardiogenic shock and heart failure for several days. ECG showed sinus tachycardia without ST elevation. The highest cTNI was 14 ng/ml. Liver and kidney functions were not injured. The pericardial drainage tube was removed 1 week after no drainage within 48 hours. The patient gradually recovered 3 weeks later. Her brain was not damaged, and she was transferred to the general ward after cardiac function recovery. Protamine was not administered to neutralize heparin. The patient had no late bleeding post-PCI. The drainage of pericardial fluid gradually decreased from 20 ml per day to nil, and the indwelling tube was removed 1 week later. The patient recovered in good condition. The patient is being followed up once a month without symptoms.