Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Syiah Kuala, Banda Aceh, Indonesia.
Division of Interventional Cardiology, Siloam Hospital, Makassar, Indonesia.
Narra J. 2024 Apr;4(1):e637. doi: 10.52225/narra.v4i1.637. Epub 2024 Mar 19.
Coronary artery perforation (CAP) is an uncommon yet serious complication. Although severe perforations (Ellis III) have become more frequent, the overall mortality rate associated with perforations (7.5%) has decreased in recent years. Unfortunately, our medical facility cannot always access a cover stent. The aim of this case report was to demonstrate the effectiveness of using a second drug-eluting stent as an alternative and successful treatment approach in a CAP patient. This is the case of a 67-year-old female with stable angina pectoris Canadian Cardiovascular Society classification III (CCS III), three-vessel coronary artery disease (CAD), who declined CABG (Syntax score of 44) and had type II diabetes mellitus. The patient underwent elective percutaneous coronary intervention (PCI), and we identified diffuse stenosis in the proximal to distal portions of the left anterior descending artery (LAD) with extensive calcification. Furthermore, there was a chronic total occlusion (CTO) in obtuse marginal (OM) 2, as well as critical stenosis in OM3, 80% stenosis in the proximal part of right coronary artery (RCA), 90% stenosis in the middle of the RCA, 90-95% in the distal RCA, and diffuse stenosis ranging from 70-80% in the distal posterolateral. During the procedure to alleviate the stenosis in the left circumflex artery (LCx), we encountered a coronary perforation classified as Ellis type III while using a 2.5/20 mm NC balloon inflated to 12 atm for 12 seconds. In response, we performed stent placement from the proximal LCx to OM2 using the Xience Xpedition drug-eluting stent (DES) measuring 2.5/28 mm. Subsequently, we conducted extended balloon inflation (intermittent) for five minutes. Despite these efforts, the coronary perforation, still classified as Ellis type III, persisted. We decided to employ intrastent stenting (a second DES strategy) with the Coroflex Isar DES measuring 2.5/28 mm, followed by prolonged balloon inflation. The outcome revealed no remaining perforation, Thrombolysis in Myocardial Infarction (TIMI) III flow, and no complications such as pericardial effusion after 48 hours of monitoring. The implantation of a second DES proved to be a practical approach for managing a significant CAP.
冠状动脉穿孔（CAP）是一种不常见但严重的并发症。尽管严重穿孔（Ellis III 型）变得更为常见，但近年来与穿孔相关的总体死亡率（7.5%）有所下降。不幸的是，我们的医疗机构并非总能获得覆盖支架。本病例报告的目的是展示在 CAP 患者中使用第二枚药物洗脱支架作为替代和成功治疗方法的有效性。这是一位 67 岁女性患者的病例，其稳定型心绞痛加拿大心血管学会分类 III 级（CCS III 级），三支血管病变（CAD），拒绝行冠状动脉旁路移植术（Syntax 评分 44 分），并患有 2 型糖尿病。患者接受了选择性经皮冠状动脉介入治疗（PCI），我们发现左前降支（LAD）近段至远段弥漫性狭窄，广泛钙化。此外，钝缘支（OM）2 存在慢性完全闭塞（CTO），OM3 存在严重狭窄，右冠状动脉（RCA）近端 80%狭窄，RCA 中段 90%狭窄，RCA 远端 90-95%狭窄，以及远侧后外侧支弥漫性狭窄 70-80%。在缓解回旋支（LCx）狭窄的过程中，我们在使用 2.5/20mm NC 球囊以 12 个大气压充气 12 秒时遇到了 Ellis Ⅲ型冠状动脉穿孔。作为回应，我们使用 2.5/28mm 的 Xience Xpedition 药物洗脱支架（DES）从 LCx 近端至 OM2 进行支架置入。随后，我们进行了五分钟的延伸球囊扩张（间歇性）。尽管如此，冠状动脉穿孔仍然被归类为 Ellis Ⅲ型。我们决定采用腔内支架置入术（第二个 DES 策略），使用 Coroflex Isar DES，尺寸为 2.5/28mm，随后进行长时间球囊扩张。结果显示无穿孔残留、心肌梗死溶栓治疗（TIMI）血流 III 级，以及在 48 小时监测后无心包积液等并发症。植入第二个 DES 被证明是治疗严重 CAP 的一种实用方法。
