A fifty-year-old female with recent history of LAD stent placement for instent restenosis, presented with chest pain and ventricular fibrillatory arrest. Angiography revealed total occlusion of her LAD stent. She underwent IVUS study, balloon angioplasty and stent placements. Post balloon dilatation of the under-deployed distal stent resulted in dual coronary artery perforations with extravasation of contrast into the LV cavity, a Type 4 Ellis coronary artery perforation (CAP). No extravasation was noted into the pericardium. Immediately a covered stent was deployed which completely sealed both perforation sites with resultant TIMI grade 3 flow. Under-deployment of stents is a common occurrence and is underappreciated. It can happen due to various reasons. Not many options exist at that time but to use a high pressure balloon and post dilate the stent. One rare complication is CAP due to post stent dilatation, with incidence reported as 0.1% to 3.0% of PCI procedures. Among the various type of CAP, Ellis Type 4 is of the least frequent however no studies have looked at its exact incidence rate. Prompt recognition and quick intervention are essential to good patient outcome. We chose to deploy a covered stent over the perforation with interim balloon tamponading. Deployment of the stent successfully sealed both the CAPs. Remarkably the patient remained stable and did not complain of chest pain throughout the procedure. The patient did well; she was discharged on dual antiplatelet therapy and is continuing to do well. We report a rare case of 2 distal LAD perforations that drained into the LV (an Ellis Type 4 CAP) caused by post stent dilatation that were successfully treated with a single covered stent. We report successful management of this case along with review of literature about management and dilemmas encountered is such instances.
The patient is a fifty-year-old female with a past medical history notable for congestive heart failure, hypertension and hyperlipidemia. In December of 2011, she sustained a myocardial infarction and received a 2.25 × 26 mm Integrity (0.0889 mm) Bare Metal Stent (BMS) to the mid Left Anterior Descending (LAD) artery for a 90% stenotic lesion. In October of 2013, she presented with chest pain (CP) and underwent coronary angiography. It revealed in-stent restenosis along the entire length of the previously placed BMS. She was re-stented with a 2.25 × 32 mm Promus Element (0.081 mm) drug eluting stent (DES) and was discharged on aspirin and prasugrel along with her other cardiac medications. Ten days later, she presented to the emergency department (ED) again with acute CP in the setting of non-compliance with prasugrel for the previous 3 - 4 days. In the ED she had a ventricular fibrillatory arrest and was resuscitated. Electrocardiography revealed ST elevation in the anterior-septal leads consistent with anterior wall myocardial infarction (MI) (
and another coronary guide was used to simultaneously engage the left coronary artery. A second 0.014” coronary wire was placed distal to the perforations, with the continuous balloon tamponade interrupted only transiently to allow wire passage. A 3.0 × 19 mm Jomed covered stent was rapidly deployed in a “quick replacement” manner. The two perforations were completely sealed, with resultant TIMI grade 3 flow confirmed on angiography (
Coronary artery perforation (CAP) during angioplasty is rare with an estimated incidence of 0.19% to 0.59% [
According to Ellis et al., the diagnosis and classification of coronary artery perforation is based on the angiographic appearance of the perforation [
Coronary artery perforations are generally managed with covered stents and reversal of anticoagulation with success rates reported in the literature of greater than 90% [
When “cavity spilling” types of perforations or coronary cameral fistulas are encountered the treatment options are unclear. Since the perforation is not spilling into the pericardial space, it is considered an artery-artery fistula. Questions arise whether it is necessary to intervene emergently. Considering that covered stents have high occlusion rates, BMS stents have high restenosis rates and embolization results in downstream infarct, the best possible treatment choice is difficult. Previous studies in coronary cameral fistulas have revealed that traumatic coronary artery-cameral fistulas (TCAF) resulting from penetrating cardiac trauma are highly lethal, and require early surgical intervention [
The IVUS study in the current case revealed an under-deployed stent, which is a common and underappreciated occurrence. In such instances, not many options exist but to use a high-pressure balloon to dilate the stent. One rare complication of high-pressure stent strut dilation is CAP with incidence reported as 0.1% to 3.0% of PCI procedures. Stenting causes vessel wall injury, the extent of which is determined by the number of stent struts involving a vessel lumen, and the degree of stent strut dilation (i.e., hence the anatomic depth at which the stent struts penetrate the vessel wall). Balloon expansion advances the strut through the internal elastic lamina, then the media, external elastic lamina, and finally adventia [
The current era stent struts are relatively thin with the diameter varying between 0.0032 - 0.0035 inches (with Resolute DES at 0.0889 mm (0.0035”), PROMUS Element DES at 0.081 mm (0.0032”), Integrity BMS at 0.0889 mm (0.0035”)). In our patient, the combined thickness of three overlapping stents is 0.2659 mm (0.0889, 0.0889, 0.0881) or greater than a quarter of a one millimeter. When deployed under high pressure one could readily hypothesize a predilection to stent perforation. Post stent dilation of this triple “stent sandwich” may have resulted in expansion of the overlapping stent struts against acutely inflamed myocardium causing a cavity spilling type of perforation.
With the CAP draining to the LV alone, there was no need for emergent pericardiocentesis, thus allowing for execution of a well thought out management plan. We chose to deploy a covered stent over the perforation with interim balloon tamponading. Deployment of the single stent successfully sealed both perforation sites. The patient remained stable and did not complain of chest pain throughout the procedure.
The patient did well post procedure, and was discharged on dual antiplatelet therapy. She is continuing to do well. This, to our knowledge, is the first reported case of an acquired coronary cameral fistula due to post stent dilatation.
This case is thought provoking as it outlines current options for CAP treatment, discusses some of the challenges in its management, and additionally highlighting the dangers of high pressure balloon dilation when there are multiple overlapping stents. There are no standard management guidelines in such instances and therapy must be customized. Severe complications associated with CAP reinforce the necessity for interventionists to take measures to minimize risks. Awareness of risk factors with careful guidewire and balloon size selection, and avoidance of stent overexpansion is vital to CAP prevention.
The authors report no financial relationships or conflicts of interest regarding the content herein.
Lawrence S. Cohen, MD. The Ebenezer K. Hunt Professor of Medicine (Emeritus). Yale University School of Medicine, New Haven, CT. We thank Dr. Cohen for his guidance and editing.