Treatment of rotablation‐induced ostial left circumflex perforation by papyrus covered stent and its fenestration to recover the left anterior descending artery during CHIP procedure

Abstract

Coronary artery perforation is a rare complication of percutaneous coronary intervention (PCI).Covered stents have been successfully used in these situations. We report a case of ostial left circumflex (LCx) artery perforation during rotablation PCI of left main coronary artery (LMCA) and LCx artery. After failed attempts to balloon tamponade the perforation, a PK Papyrus covered stent was deployed from proximal LCx into LMCA. This resulted in acute exclusion of the left anterior descending (LAD) artery from coronary circulation. Using a dual lumen catheter, a stiff wire was advanced through the side port toward the occluded LAD to fenestrate the membrane of the covered stent. A series of balloons were used to dilate the fenestration in the covered stent to restore a normal flow into the LAD. K E Y W O R D S CHIP, coronary perforation, papyrus covered stent, rotablation 1 | INTRODUCTION Coronary artery perforation is one of the most dreadful complications of coronary intervention with an incidence of 0.1-0.6% of cases. 1 Coronary covered stents play a crucial role in the management of this complication. One of the drawbacks of the covered stents when used in bifurcation perforation is an occlusion of the branch vessel and this case depicts one of the management strategies to overcome this mischief. 2 | CASE An independent 91-year-old man presented with a non-ST-elevation myocardial infarction on the background of crescendo angina over 3 months and severe aortic stenosis. His only past medical history included mitral valve repair 24 years ago. On presentation his electrocardiogram had dynamic ischemic changes in the inferolateral leads. His bloods revealed troponin I at 7.2 μg/L (normal <0.040 μg/L) creatinine at 82 μmol/L (81-143 μmol/L), hemoglobin 177 g/L (120-180 g/L). Transthoracic echocardiogram (TTE) showed evidence of global left ventricular (LV) systolic dysfunction with LV ejection fraction (LVEF) of 35%, mild mitral regurgitation and low-flow low gradient severe aortic stenosis (aortic valve area [AVA] 1.1 cm 2 , indexed AVA 0.56 cm 2 , peak velocity 2.7 m/s, mean pressure gradient 16 mmHg, DPI 0.24). Coronary angiography revealed severe three vessel coronary artery disease with critical distal left main coronary artery (LMCA) stenosis, 90% ostial left circumflex (LCx) stenosis, 80% diffuse proximal left anterior descending (LAD) stenosis and moderate diffuse right coronary artery disease (Figures 1 and 4).He was deemed not a surgical candidate given his advanced age and previous sternotomy. His Society of Thoracic Surgeons Score (STS) score was 12% and EUROSCORE II was 13.6%. He was reviewed by the Heart Team and decision was made to proceed with complex percutaneous coronary intervention (PCI) of LMCA, LCx, and LAD with Impella CP mechanical circulatory support in the first instance and followed by transcatheter aortic valve replacement (TAVR) in the near future. | PROCEDUREVia right radial artery, a 7-in-6 Fr sheath was inserted to accommodate 7 Fr EBU guide catheter. 6 Fr sheath in left femoral a...

A Novel Hybrid Approach to the Treatment of a Left Main Coronary Artery Aneurysm

“…Unfortunately, in discovering that his saphenous vein graft to ramus was not patent, we had to change our strategy. We were able to extrapolate the idea of fenestrating through a covered stent, to allow flow into another territory from other case reports ( 6 ).…”

Circumflex Rescue After Left Main Covered Stenting Using a Stiff Wire, Angled Microcatheter, and Stent Target

“…This situation has been seen in 2 previous case reports, but the method of side branch rescue differed slightly. 4,5 In those 2 cases, the side branch was recovered using a dual-lumen microcatheter rather than an angled microcatheter. An angled microcatheter may allow for a more directed side branch puncture and rapid fenestration dilation.…”

Hybrid Treatment for a Distal Left Main Coronary Artery Aneurysm ― Coronary Artery Bypass Grafting and Surgical Ligation Followed by Intraoperative Covered Stent Implantation ―

“…PCI with intentionally implanting a covered stent across the main branch and side branch fenestration may be an alternative, but its safety and efficacy remain unclear. 1 A hybrid approach for treating a distal LMCA aneurysm with intraoperative implantation of a covered stent, after CABG and ligation of the inflow artery (main branch) to the CAA, may be feasible in surgically challenging cases with resection for LMCA aneurysms.…”