Coronary artery perforation is a rare but potentially catastrophic complication of percutaneous coronary intervention (PCI).1–3 The availability of polytetrafluoroethylene (PTFE) covered stents made a significant impact on the treatment of this complication. Still there are situations in which the perforation site is distal and not amenable to covered stent treatment. We describe a case of right coronary artery (RCA) perforation during a recanalization attempt of a chronic total occlusion complicated by impending tamponade and treated with transcatheter injection of polyvinyl alcohol (PVA) foam embolization particles. Case report. A 71-year-old male with a history of hypertension and hypercholesterolemia underwent PCI due to stable angina and positive exercise stress test. The coronary angiogram revealed a 50% stenosis of the mid-left anterior descending artery and a total occlusion of the RCA (Figure 1). The left ventriculogram showed moderate hypokinesia of the inferior wall and basal segment of the left ventricle. Aspirin (100 mg) and clopidogrel (75 mg loading dose) were given 3 days prior to the procedure as an antiplatelet regimen. An ad hoc PCI was attempted to recanalize the proximal RCA occlusion via the right femoral artery. Anticoagulation was achieved using unfractionated heparin at a dose of 70 mg/kg targeted to maintain an activated clotting time of 250 seconds. After engagement of a 6 Fr AL1 guiding catheter at the RCA ostium, the occlusion was unsuccessfully navigated first with a 0.014-inch WHISPER (Guidant, Santa Clara, California) and then a 0.014-inch MIRACLE 4.5 (Asahi Intecc Co, Ltd, Aichi, JAPAN) followed by a 0.014-inch CONQUEST guidewire (Asahi Intecc Co., Ltd., Aichi, Japan). Moreover, we experienced difficulty in crossing the occluded lesion with an over-the-wire MAVERICK 1.5 x 20 mm balloon catheter (Boston Scientific, Scimed, Maple Grove, Minnesota). The tip of the CONQUEST wire was buckled at the proximal RCA, and we noticed minimal extravasation of contrast dye from the proximal part of the RCA with peri-arterial staining without free-flowing of the dye (Figures 2A, and 2B). Consequently, the patient complained of chest discomfort and became progressively hypotensive. Immediate fluoroscopy revealed considerable dye collection in the pericardial space. This finding was verified by transthoracic echocardiography which showed hypoechoic space at the posterolateral space, with mild right heart compression, confirming the presence of significant pericardial effusion. Protamin 50 mg was given intravenously and emergency pericardiocentesis resulted in aspiration of a total of 200 cc of blood. Inflation of the balloon proximally to the perforation in order to seal it did not result in cessation of blood flow to the pericardial space. On the contrary, we noticed further dye collection on the fluoroscopy. Then we tried to occlude the proximal RCA artery by injecting PVA embolization particles. A 2.3 French TRANSIT catheter (Cordis Neurovascular Inc., Miami, Florida) was advanced through a 0.014-inch BALANCE MIDDLEWEIGHT UNIVERSAL 190 wire (Guidant, Santa Clara, California) immediately proximal to the perforation site. Consequently, a 3 cc solution of PVA-300 particles (300–500 microns) mixed with dye was slowly injected through the central lumen of the catheter. No more staining was observed at the distal arterial bed, suggesting thrombotic occlusion (Figure 3). By that time, the patient regained hemodynamic stability. Follow-up echocardiograms showed decreased pericardial effusion and complete resolution of the pericardial effusion 4 days later. The patient made an uneventful recovery with no new electrocardiographic changes and no rise in serum creatine kinase levels and was discharged in stable condition 5 days later. Discussion. Coronary artery perforation is a rare but potentially catastrophic complication of PCI.1–4 It has been reported to occur in 0.1% to 3.0% of lesions treated with various intervention techniques and accounts for 20% of referrals for emergency bypass surgery.1–3,5 Old age, female gender, calcified and tortuous arteries, and the use of atheroablative devices have all been implicated with a higher incidence of perforation.1,2,6 It has also been shown to be more frequent in the left circumflex and right coronary arteries, in long, and eccentric lesions.1,2,6 The management of coronary artery perforation varies with type and the mechanism of perforation.2,4,6 In general, guidewire perforations are more benign and scarcely result in major adverse sequelae compared to the perforations caused by balloons, stents, and atheroablative devices which may result in hemopericardium and tamponade.3 Regardless of the cause, initial management of this complication in order to stabilize the patient includes sealing with inflation of a conventional or a perfusion balloon catheter, reversal of the anticoagulation, and pericardiocentesis if needed.2 Proximal or mid-perforations can be managed with PTFE-covered or autologous vein graft stents when the vessel involved is of suitable diameter to accept such a stent.7,8 Microcoils, gelatin sponge or foam, and PVA foam can be used in distal perforations.6,9–11 Compared to coil embolization, PVA or gelatin foam is suitable for relatively small–sized (less than 1 mm) distal artery perforations.6 This approach is particularly useful when the exact site of the perforation cannot be clearly visualized and it is very distal. Another possible advantage is that the infusion of the particles can also be performed through an over-the-wire balloon catheter while keeping the balloon inflated to prevent further leak. In this last circumstance, it is important to utilize a small-sized PVT particle (
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