Coronary Extramural Hematoma Caused By Perforation During Chronic Total Occlusion Intervention ; Treated With a Cypher Stent

- Operator : Seung-Jung Park

Coronary Extramural Hematoma Caused By Perforation During Chronic Total Occlusion Intervention ; Treated With a Cypher Stent

- Operator: Seung-Jung Park, MD, PhD, Korea
Clinical history
Forty-one year old man presented with resting chest pain for 2 months. He had a hypertension as coronary risk factors. His baseline ECG showed normal. Treadmill test was positive at early stage. Baseline echocardiogram and cardiac enzymes were normal.
Baseline coronary angiography
The initial left coronary angiogram showed total occlusion of the 1st obtuse marginal branch and near normal LAD (Figure 1, Figure 2). Good collateral flow was seen from left coronary artery to the right coronary artery (RCA) (Figure 3). The right coronary angiogram showed total occlusion of middle RCA (Figure 4).
Procedure
We obtained right common femoral artery access and inserted a 7 F femoral sheath through right femoral artery. The right coronary was engaged with a 7 F AL2 guiding catheter for good guiding support. For recanalization of chronic total occlusion (CTO), a 0.014 inch Shinobi guidewire with OTW system was selected first to cross the lesion. Just after advancing the Shinobi guidewire into the proximal RCA, extravasation of contrast agent was noted (Figure 5 ). Because Dr. Park thought the perforation of RCA was not severe and the coaxial alignment of the guiding catheter with RCA was not good, he planed to treat the perforation with a stent after crossing the CTO lesion with a Judkins guiding catheter. After changing a guiding catheter with a JR with 3.5cm curve, the CTO was crossed with a Shinobi guidewire with OTW system (Figure 6 ). After predilation (Figure 7 ), IVUS was performed. It showed the tight diffuse stenoisis from the middle to the proximal RCA and extramural hematoma from the proximal RCA to the ostium of RCA at 8-1 O¡¯clock (Figure 8 ). Following coronary angiogram showed sustained minimal extravasation with stable hemodynamics of the patient (Figure 9 ). Then three Cypher stents (two 3.0x28mm, one 3.5x18mm) were implanted with overlapping from the distal lesion to the RCA ostium (Figure 10, Figure 11, Figure 12). Following coronary angiogram and IVUS image showed good result with sealing of coronary perforation (Figure 13, Figure 14, Figure 15).
The left coronary was engaged with a 7 F AL2 guiding catheter for good guiding support. Although wiring into the obtuse marginal branch with OTW system was successful, recanalization of side branch oriented inferiorly could not be done. Therefore, a 2.5x18mm Cypher stent was implanted crossing the side branch. Final angiogram showed a successful result in the major branch of the obtuse marginal branch.

Leave a comment

Sign in to leave a comment.