Coroanry Artery Rupture During Bare Metal Stenting, Treated by Additional Bare Metal Stent

- Operator : Charles Chan

Coroanry Artery Rupture During Bare Metal Stenting, Treated by Additional Bare Metal Stent

- Operator : Charles Chan, MD, PhD, Singapore

Case presentation
A sixty-five year old lady presented with Non-ST elevation myocardial infarction 1 week ago. She was pretreated with aspirin, clopidogrel, and subcutaneous fraxiparene for 1 week by her referring physician.
Baseline Coronary Angiography
Coronary showed a distal left main stem of 25% stenosis, 90% ostial stenosis of LAD (Figure 1). The LCX and RCA are normal.
Procedure
A 3.0mm cutting balloon was initially used to dilate the lesion. A 5.0 x 16mm Express II stent was then placed from the distal left main to the proximal LAD and inflated at 12atm after stenting (Figure 2). Following shot showed extravasation of contrast agent suggesting coronary artery rupture. Patient became quickly hypotensive and a 2D echocardiogram showed pericardial effusion located posteriorly. Heparin was completely reversed with protamine sulphate and an attempted pericardiocentesis was unsuccessful because of the posterior location of the pericardial effusion. However, the patient stabilized with fluid challenge and repeat coronary angiogram showed that the flow in left circumflex artery was impaired and the dye was still flowing freely into the pericardium from the proximal left anterior descending artery (Figure 3). A 4.5mm x 12mm Express II stent was deployed just after the orifice the circumflex artery (Figure 4). After stenting, there was minimal extravasation of contrast dye (Figure 5). A 0.014¡± floppy wire was then maneuvered around the stent struts into the circumflex artery and a 3.0mm balloon inflated at the ostial left circumflex artery (Figure 6).
After procedure, there was good antegrade flow in the left circumflex (Figure 7, Figure 8). The patient was haemodynamically stable without any inotropic support. The patient was then transferred to the operating room for surgical pericardial drainage. The patient made an uneventful recovery and was discharged 1 week later. There was no evidence of a new myocardial infarction on the predischarged ECG.

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