Doost Ata, Mabote Thato, Clugston Richard, Ihdayhid Abdul Rahman
Fiona Stanley Hospital, 11 Robin Warren Drive, Murdoch, Western Australia 6150, Australia.
Harry Perkins Institute of Medical Research, University of Western Australia, Perth, Australia.
Eur Heart J Case Rep. 2022 Oct 15;6(10):ytac410. doi: 10.1093/ehjcr/ytac410. eCollection 2022 Oct.
Intravascular lithotripsy (IVL) is a new modality in treatment of calcified coronary lesions which improves procedural outcomes. Coronary perforation is an extremely uncommon but potentially catastrophic complication of percutaneous coronary intervention (PCI) and IVL therapy.
We report a case of an elective PCI to a calcified left anterior descending (LAD) and diagonal bifurcation lesion in a 65-year-old man. LAD was treated with two stents. Despite high pressure non-compliant balloon inflation, a focal area of under-expansion remained. IVL successfully treated the under-expansion but was complicated with a large coronary perforation. The perforation was successfully sealed with a PK-PAPYRUS covered stent sacrificing the diagonal branch. Patient remained stable until 3 hours later when he developed tamponade requiring urgent pericardial drainage. Repeat angiography demonstrated recanalization of the diagonal branch and ongoing contrast extravasation along its course. Optical coherence tomography intracoronary imaging was used to delineate the mechanism of ongoing bleeding. This demonstrated an interrupted elastic membrane of the covered stent, potentially caused by underlying fractured calcium. Therefore, a second overlying PAPYRUS stent was deployed which satisfactorily sealed the perforation.
IVL is an emerging less invasive treatment for calcified coronary stenosis but could be associated with drastic complications. This case highlights the importance of awareness of IVL-related coronary perforation and the potential limitation of new generation thinner-wall covered stents. Intracoronary imaging plays an important role in identifying mechanisms of stent failure, tailoring treatment, and optimizing outcomes.
血管内碎石术（IVL）是治疗钙化冠状动脉病变的一种新方法，可改善手术效果。冠状动脉穿孔是经皮冠状动脉介入治疗（PCI）和IVL治疗极其罕见但可能具有灾难性的并发症。
我们报告一例65岁男性择期PCI治疗钙化的左前降支（LAD）和对角支分叉病变的病例。LAD置入了两枚支架。尽管使用高压非顺应性球囊扩张，但仍有一个局部扩张不足的区域。IVL成功治疗了扩张不足，但并发了一个大的冠状动脉穿孔。使用PK-PAPYRUS覆膜支架封堵穿孔，牺牲了对角支。患者在3小时前一直保持稳定，之后出现心包填塞，需要紧急心包引流。重复血管造影显示对角支再通，且沿其走行有持续的造影剂外渗。采用光学相干断层扫描冠状动脉内成像来明确持续出血的机制。结果显示覆膜支架的弹性膜中断，可能是由潜在的钙碎片所致。因此，又置入了一枚覆盖其上的PAPYRUS支架，成功封堵了穿孔。
IVL是一种新兴的、侵入性较小的钙化冠状动脉狭窄治疗方法，但可能会伴有严重并发症。该病例强调了认识IVL相关冠状动脉穿孔的重要性以及新一代薄壁覆膜支架的潜在局限性。冠状动脉内成像在识别支架失败机制、制定治疗方案和优化治疗效果方面发挥着重要作用。
