coronary artery perforation ( cap ) which occurs either during or following percutaneuous coronary intervention ( pci ) is an infrequent complication , but one of the most disastrous complications of this cardiovascular surgery procedure.1 - 9 ) it has been related to vessel wall penetration with guidewire , balloon overexpansion or rupture , atheroablative techniques , and stent implantation .
some reports have shown that helical platinum microcoil embolization was used for cap.10 - 15 ) contrasting the usual expectation that an embolized artery will not show any blood flow , this report shows preserved normal blood flow at the embolization site on the 1 year follow - up angiography , following emergent lifesaving microcoil embolization , in a patient with uncontrolled ellis grade 3 guidewire - induced cap , resulting in cardiac tamponade . in the literature , there are no other similar case reports from a follow - up angiography after microcoil embolization , especially in a case such as the one presented herein , where the flow was maintained at the embolized site .
a 51-year - old male patient with a 30 pack - year current smoking presented with a recent onset of exertion chest pain .
the treadmill test provoked severe chest pain , without st changes on the electrocardiography ( ecg ) , at stage 2 of the modified bruce protocol .
the patient underwent elective coronary angiography via the left femoral approach , which revealed a discrete critical narrowing of the middle left anterior descending artery ( lad ) , just distal to the first diagonal branch ( d1 ) ( fig .
a 7 fr jl4 guide catheter ( cordis , miami , fl , usa ) was used to engage the left main coronary artery , and a 0.014 " atw guidewire ( cordis , miami , fl , usa ) was passed into the distal lad , without difficulty .
the proposed treatment was a cross - over stenting followed by provisional t stenting at that lesion site .
angioplasty was performed twice with the ryujin plus ( terumo , tokyo , japan ) 3.510 mm balloon at 6-atm ( up to 3.5 mm ) inflation . a zotarolimus - eluting stent
( endeavor resolute , medtronic , minneapolis , mn , usa ) 4.015 mm stent was deployed , with 12-atm ( up to 4.08 mm ) inflation .
the repeat angiogram showed adequate deployment of the stent , but a jailed d1 ( fig .
an attempt was made to pass into d1 using a 0.014 " choicept guidewire ( boston scientific , miami , fl , usa ) through the instent .
after initially inflating a sprinter ( medtronic , minneapolis , mn , usa ) 3.015 mm semi - compliant balloon , up to 3.18 mm at the d1 ostium , ' kissing ' balloon angioplasty , using a sprinter 3.515 mm for the lad and a sprinter 3.015 mm for d1 , was finally performed ( fig .
three hours after pci , he complained of more severe chest pain , dyspnea , tachypnea and heavy sweating .
an emergent echocardiogram was taken at the patient 's bedside , under the suspicion of a cardiac tamponade , due to delayed extravasation after pci .
it showed a pericardial effusion of less than 10 mm , as well as the collapse of the right atrium .
emergency pericardiocentesis was performed and over 100 ml of bloody pericardial fluid was initially drained .
pericardial fluids were drained continuously and blood was transfused through the peripheral vein , with the expectation that it will stop the extravasation spontaneously .
considering the drainage rate of the pericardial fluid at over 200 ml / hr , a large perforation of the coronary artery at the stenting site was suspected . however , an emergent angiogram showed massive extravasation ( ellis grade 3 coronary perforation ) at the far distal area of d1 ( fig .
an attempt was made to recross d1 and a sprinter 3.015 mm semi - compliant coronary balloon with low pressure was inflated at the middle portion of d1 .
however , the perforation could not be sealed and continuous leakage occurred after the balloon 's deflation , even after an inflation period of over 60 minutes .
we attempted to occlude the d1 branch via a microcoil embolization to repair the perforation site completely . a microferret superselective catheter ( cook , sandet , denmark )
one 0.018-inch and 14.2-mm - long tapered microcoil ( 104 mm in diameter ; tornado ; cook , bloomington , in , usa ) was quickly released , using the microcatheter 's supporting guidewire ( transend 300 , boston scientific , miami , fl , usa ) as a pusher .
a post - coil lad arteriogram demonstrated the total occlusion of d1 and no further extravasation ( fig .
, the post procedure echocardiogram revealed an ejection fraction of 60% , with mild hypokinesia on the apical lateral and apical anterior walls , and no pericardial effusion .
the peak infarct size , as measured using serum biomarkers , was a troponin of 2.65 ng / ml and a creatinine phosphokinase - mb of 100.8 ng / ml . the patient was uneventful and discharged 5 days later in a stable condition .
the treadmill test provoked chest pain at stage 5 , with a 1 mm st depression on the ecg , and the echocardiogram showed no interval change . for 12 months after pci , the patient had several episodes of chest pain and dyspnea on exertion .
angiographic findings of d1 showed a normal flow without delay ( fig . 2c ) .
cap may range clinically from guidewire - related microperforations , resulting in minimal dye staining without haemodynamic consequences , to vessel rupture followed by active extravasations of blood and dye into the pericardial space , leading to tamponade and sudden haemodynamic collapse .
it has been reported at variable rates , depending on the procedures performed , lesions treated and devices used . in the recent registries , perforation has been reported to occur in 0.17 - 1.5% of all patients undergoing pci.9)16 - 18 ) the incidence of these complications has been increased by the use of debulking devices , such as high - speed rotational atherectomy and directional coronary atherectomy.2)3)5 - 7)17 ) guidewire - induced perforation seems to be the most frequent cause of cap - accounting for 20 to 68% of cap incidents.2)3)5 - 9)16 - 18 ) in pci of complex lesions , including chronic total occlusions and bifurcation lesions , the use of both hydrophilic and heavy - weight guidewires has also increased the frequency of this complication.2)4)7)9)17 ) a choicept wire was used for crossing the d1 branch in this case .
we suspected that the hydrophilic guidewire - induced damage occurred with the attempt to treat the jailed branch , using the ' kissing ' balloon technique .
this choicept wire was coated with a highly lubricious hydrogel and was moderately stiff , compared with the new - generation guidewires . due to this low coefficient of friction and easy distal migration,10)11)15)19 ) caution should be exercised in positioning the tip of the guidewire distally . after the perforation diagnosis ,
treatment strategy varies , according to the clinical situation , i.e. , the size of the perforation , the extent of contrast extravasation , and the hemodynamic status of the patients .
the initial management involves the inflation of an angioplasty balloon proximal to or at the level of the perforation to seal the leak , and pericardioentesis can be performed if cardiac tamponade is present .
depending on the bleeding control , complete management modalities should be considered - from surgery to less invasive percutaneous techniques : covered stents / grafts or thrombus inducing therapies , such as polyvinyl alcohol , autologous blood or intracoronary bead injection .
if a cardiac surgeon were unavailable , one might have to choose another option for controlling the patient 's bleeding . because a covered stent is bulky , has a large diameter ( of over 3 mm ) , and is not easy to pass through the side hole of a stent in the parent artery ,
this device could not be used with the continuous bleeding from the perforation in this case . in the event that the perforation is in a small sized branch ,
the operator may consider excluding the whole branch by coiling , bead seeding , or implanting other thrombogenic agents directly into the branch .
the use of the microcoil was very effective in the patient presented herein . in recent studies ,
the prevalence of microcoil embolization as a treatment option of cap was 0.1 - 4%.1)8)17 ) it is not common but it may play an important role when traditional management for cap has failed .
microcoils have been used as permanent embolic agents for occlusion of cerebral aneurysms , gastrointestinal hemorrhage , and other peripheral vascular therapeutic maneuvers .
however , due to the permanent loss of the vessel lumen beyond the site of the microcoil placement and the subsequent infarction , their use in the coronary arteries should be limited to distal small - vessel perforation in life - threatening circumstances , in which no other options are readily available .
the tornade embolization microcoils ( cook ) have a soft platinum structure with synthetic fibers that maximize thrombogenicity
. moreover , their helical configuration maximizes the coil exposure to the cross - section of the lumen for the disruption of the flow . to allow proper adherence to the vessel wall ,
the coil size should be slightly ( 25% ) larger than the target vessel diameter .
this case describes the successful management of cap , with the sacrifice of the d1 via coil embolization .
nevertheless , at the follow - up angiography , a patent blood flow was evident at the site where the microcoil was inserted .
this case , therefore , is not only the first angiographic result of microcoil embolization presented to date , but also , particularly , the first example of maintenance of the blood flow at the embolized site , which was against our expectations of complete occlusion .
the best hypothesis is that , although a very large microcoil was inserted , initially inducing a thrombus , this thrombosis state could not be maintained due to inadequate adherence to the vessel under dual antiplatelet therapy .
although some perforations are quite evident in the catheterization laboratory , others remain initially occult , only to become clinically apparent hours after the procedure .
cardiac tamponade complications occur in 11 - 46% of patients experiencing cap after pci.1 - 4)7 - 9)16)17 ) delayed tamponade comprised 20 - 60% of these tamponade complications,3)4)20 ) and was common in the perforations ( e.g. , ellis type i ) induced by either guidewire or glycoprotein iib / iiia inhibitor use.16)20 ) thus , this diagnosis should remain high on the list of differential diagnoses of post - pci hypotension . in these cases ,
the diagnosis of cap should be ruled out , especially if retroperitoneal bleeding is not present .
close observation is strongly advised in all pci cases because , if not recognized , bleeding from cap can rapidly lead to death from cardiac tamponade .
cap is a rare , but disastrous complication of pci . in selected cases of distal coronary perforations ,
microcoil embolization may be a reasonable alternative therapeutic approach . however , an obvious drawback of this approach is the permanent loss of the vessel lumen beyond the site of the microcoil placement and the subsequent infarction .
therefore , this approach should be limited either to life - threatening circumstances , in which no other options are readily available , or to the treatment of very distal perforations , where the amount of myocardium that is jeopardized is minimal . despite a large , hemodynamically significant perforation , the successful management of cap with the sacrifice of the d1 via coil embolization is described in this case .
a notable , unexpected result was evident at the patient 's follow - up one - year angiography , i.e. , a patent blood flow existed at the site where the microcoil was inserted .
 coronary artery perforation ( cap ) after percutaneous coronary intervention is a rare , but serious complication . 
 it can cause cardiac tamponade , acute myocardial infarction or death . 
 the treatments of cap involve prolonged balloon inflation , emergent surgery , coil embolization , and implantation of covered stent . 
 we have successfully performed the emergent microcoil embolization in a patient with uncontrolled ellis grade 3 guidewire - induced cap resulting in delayed cardiac tamponade . 
 contrasting our usual expectation , the 1-year follow - up angiography showed a patent flow at the embolized site . 
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