Gupta Himanshu, Kaur Navjyot, Sharma Yashpaul, Lim Soo Teik
Advance Cardiac Center, Sector 12, Post Graduate Institute of Medical Education & Research, Chandigarh 160012, Indi a.
5 Hospital Drive, Level 2 Pharmacy, National Heart Centre Singapore 169609.
Eur Heart J Case Rep. 2021 May 16;5(5):ytab173. doi: 10.1093/ehjcr/ytab173. eCollection 2021 May.
Despite improvement in available tools and techniques, procedural complications like coronary perforation can occur during percutaneous coronary intervention (PCI). Severe proximal coronary perforations are usually caused by balloon and vessel size mismatch but can also occur with appropriately sized balloons or stents if the coronary vessel has very eccentric calcification or if there is negative remodelling of the vessel.
A 74-year-old man with a history of type II diabetes mellitus, hypertension, and chronic coronary syndrome (previous PCI 10 years before) presented with unstable angina of 2 weeks of duration. Coronary angiography revealed a patent stent in left anterior descending artery, significant disease in left circumflex artery and diffuse calcified lesion in dominant right coronary artery (RCA). During angioplasty of RCA, the patient developed severe Ellis grade III perforation, which was successfully managed with modified double guiding catheter 'Ping Pong' technique. In this technique, the already engaged 7 French (F) Amplatz Left 1 guide catheter was used to deliver the bulky covered stent in highly tortuous and calcified RCA while a second 6F guide catheter (Judkin Right) introduced through contralateral femoral access was used for introducing the balloon, which initially sealed the perforation and subsequently acted as a distal anchor to provide strong support to deliver the covered stent.
In a case of severe coronary perforation, modified Ping Pong technique using a small-sized second guide catheter complimentary to the first guide catheter, can be used to deploy bulky covered stent.
尽管现有工具和技术有所改进，但在经皮冠状动脉介入治疗（PCI）过程中仍可能发生冠状动脉穿孔等手术并发症。严重的冠状动脉近端穿孔通常由球囊与血管尺寸不匹配引起，但如果冠状动脉血管存在非常偏心的钙化或血管发生负性重构，即使使用尺寸合适的球囊或支架也可能发生。
一名74岁男性，有2型糖尿病、高血压和慢性冠状动脉综合征病史（10年前曾接受PCI），因持续2周的不稳定型心绞痛就诊。冠状动脉造影显示左前降支有一枚通畅的支架，左旋支有明显病变，优势右冠状动脉（RCA）有弥漫性钙化病变。在RCA血管成形术期间，患者发生了严重的埃利斯III级穿孔，采用改良双导引导管“乒乓球”技术成功处理。在该技术中，已置入的7法国（F）Amplatz左1导引导管用于在高度迂曲和钙化的RCA中输送大型覆膜支架，而通过对侧股动脉入路引入的第二根6F导引导管（Judkin右）用于引入球囊，球囊最初封闭穿孔，随后作为远端锚定物，为输送覆膜支架提供有力支撑。
在严重冠状动脉穿孔的病例中，可使用与第一根导引导管互补的小尺寸第二根导引导管的改良乒乓球技术来部署大型覆膜支架。
