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case_images: (A) Baseline electrocardiogram showing Extensive AWMI. (B) Transthoracic ECHO showing hypokinesia of anterior and lateral walls with an estimated EF of 30%.
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case_images: The baseline ECG indicated an extensive anterior wall myocardial infarction, and a bedside echocardiogram revealed an ejection fraction (EF) of 30% with hypokinesia in the anterior and lateral walls (Figure 1).
case_images: (A) Initial angiogram showing thrombotic occlusion as well as calcification. (B) Angiographic view post dilatation showing deformity in inflated balloon. (C) Angiographic view showing coronary artery perforation (Ellis Type III).
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case_images: Following heparin administration, a coronary angiogram via right radial access was performed, revealing normal left main stem and left circumflex arteries, with diffuse disease in the mid-left anterior descending artery followed by total occlusion (thrombotic) and significant calcification of proximal vessel the right coronary artery (RCA) showed subtotal occlusion with faint antegrade and retrograde filling (Figure 2A). TIMI III flow in the distal vessel. Given the Long length of the lesion, DES (Xience Xpedition) 3.5 x 38 mm was deployed in the proximal segment, but significant under expansion due to eccentric calcification and residual stenosis at the distal edge necessitated further intervention with a 3.5 x 12 mm non-compliant balloon at multiple sites under high pressure. Ten minutes into the procedure, fluoroscopy revealed balloon deformation (Figure 2B), and a check injection indicated an Ellis Type III perforation (Figure 2C).
case_images: (A) Post balloon tamponade of 10 min with persisting perforation. (B) Thrombus inside the stent followed by no reflow due to thrombus in distal vessel, pigtail catheter for draining cardiac tamponade, and persistent perforation. (C) Deployment of homemade cover stent.
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case_images: Repeat angiography showed persistent perforation with cardiac tamponade and haemodynamic instability (Figure 3A). Thirty minutes into the procedure, emergency pericardiocentesis was performed (Figure 3B), and balloon tamponade was continued for an additional 10 min, leading to slight haemodynamic stabilization with a blood pressure of 70/50 mmHg under high ionotropic support. At 55 min intra-procedure, check injections revealed massive perforation and thrombus with distal no-reflow (Figure 3B). The stent, now encased in the dressing, was deployed at a pressure of 12 atm, effectively sealing the perforation. (Figure 3C).
case_images: (A) Acute stent thrombosis. (B) Export catheter. (C and D) Final view showing TIMI II flow in distal vessel.
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case_images: However, proximal stent thrombosis resulted in no reflow in the vessel (Figure 4A). Manual thrombus aspiration was conducted using an Export Advance catheter (Figure 4B), and pharmacotherapy with nitroglycerin (100 microg), adenosine, (200 microg) and adrenaline (100 microg) was administered. TIMI II flow, a sealed coronary perforation (Figure 4C) and no further accumulation of pericardial effusion on echocardiography. The patient was then transferred to the ICU with the total procedure lasting 2 h 10 min, where glycoprotein IIb/IIIa inhibitors were continued for 6 h.
case_images: (A and B) Re-check angiography after 72 h (TIMI III flow, no residual thrombus).
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case_images: III flow with patent stents and reappearance of previously lost septal and diagonal branches (Figure 5A and B). Ionotropes were gradually tapered, and the patient was discharged in stable condition after 7 days, with continued follow-up planned which lasted upto 6 months after which the patient was lost to follow-up and passed away at home 13 months post procedure due to unknown reasons.