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case_images: Angiographic Lesion Assessment. (A) Left coronary system with serial stenoses of the right circumflex artery. (B) Left coronary system with stenosis of the mid left anterior descending artery. (C) Right coronary artery with serial severe stenoses of the mid segment. (D) Tortuosity of the right coronary artery.
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case_images: Chronic Obstructive Lung Disease) stage IV, osteoporosis, and unstable gait of multifactorial origin. Coronary angiography via the right radial access showed significant coronary artery disease with high-grade stenosis of the left circumflex artery (Figures 1A and 1B) and serial high-grade stenoses of the right coronary artery (RCA) (Figures 1C and 1D).
case_images: Management of Distal Wire Perforation. (A) Distal perforation of Sion Black wire. (B) Distal vessel perforation and bleeding. (C) Balloon occlusion of the posterior descending artery. (D) Coiling of the distal posterior descending artery. (E) Perforation of the posterior descending artery with intramyocardial bleeding.
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case_images: After difficult predilatation of the severely calcified RCA, a distal wire perforation of the posterior descending artery (PDA) was noted (Figures 2A and 2B). Balloon occlusion of the PDA with the 2.5 SC balloon (Figure 2C) was unsuccessful. Due to ongoing bleeding from the perforation, predilatation of the RCA with the 2.5 SC balloon was performed to allow parallel wiring with a workhorse wire (Sion Blue) and placing of a total of 4 Azur CX coils (Terumo Corporation) through a Progreat microcatheter (Terumo Corporation) (Figure 2D). Although there were no signs of pericardial tamponade and bedside echocardiography showed only minor effusion, ongoing bleeding into the myocardium and epicardial fat tissue from the distal wire perforation in the PDA was noted on the angiogram (Figure 2E).
case_images: Acute Stent Thrombosis. (A) Acute stent thrombosis, with no reflow. (B) Reperfusion after administration of additional heparin. DES = drug-eluting stent.
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case_images: The stent thrombosis could be reverted by giving an additional 5,000 U of unfractionated heparin (Figures 3A and 3B).
case_images: Vessel Rupture. (A) Ongoing bleeding from the distal perforation (dashed line) despite 3.0 balloon (white arrow). (B) Vessel rupture (white arrow) due to upsizing to 3.5 balloon.
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case_images: Additional balloon occlusion with a larger 3.5 SC balloon was performed, which was complicated by vessel rupture at the crux (Figures 4A and 4B).
case_images: Dislodged Stent Graft. (A) Angiogram of the dislodged stent graft. (B) Illustration of the dislodged stent graft. White = DES in place; black = dislodged stent graft; blue = Amplatz Left 0.75 guide catheter. Abbreviation as in Figure 3.
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case_images: The graft got trapped within the DES in the proximal RCA and dislodged from the balloon (Figures 5A and 5B).
case_images: Self-Made Snare. (A) Angiogram of the snare used to recover the dislodged DES. (B) Illustration of snaring the stent (gray) on the guidewire (black) using a 6-F Amplatz Left 0.75 guide catheter (blue) and a Sion Blue wire (green) through a microcatheter (gray) pinned inside the guide catheter using a 2.5 semi-compliant balloon (blue). (C) Picture of the recovered stent and fractured Sion Blue wire. Abbreviation as in Figure 3.
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case_images: With no dedicated large loop snare at hand, a self-made snare was used to recover the distorted, elongated stent and the remaining part of the fractured Sion Blue (Figures 6A to 6C).
case_images: Final Angiogram. (A) Final angiogram of the coiled posterior descending artery and the covered vessel rupture. (B) Final angiogram in left anterior oblique view with the reperfused proximal to distal right coronary artery.
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case_images: RCA and after dilatation with a 3.5-mm noncompliant balloon (Sapphire NC24, OrbusNeich), and a DES with high radial force (4.0 x 28-mm Synergy Megatron) was used to crush the stent graft to the vessel wall (Figures 7A and 7B). Rapid response of the resuscitation team helped to de-escalate the situation and allowed the intervention team to focus and resolve the case.