Coronary Artery Fistulous Perforation Effectively Managed During Chronic Total Occlusion Recanalization: A Case Report

Background Coronary perforation is a feared complication of chronic total occlusion‐percutaneous coronary intervention (CTO‐PCI), especially in large vessel perforations, which often require implantation of covered stents (CS). However, the deployment of multiple CSs may not always be effective. Therefore, identifying the underlying formation mechanism and providing feasible solutions are very meaningful. Case Presentation This case presented an Ellis II grade perforation during the mid‐left anterior descending (LAD) artery segment during LAD CTO recanalization. Three CS were implanted around the perforation site. However, continuous extravasation persisted even after adequate post‐dilation for CS. After identifying the potential fistulous perforation inlet, one drug‐eluting stent (DES) was deployed from the distal left main trunk (LMT) to the proximal LAD to successfully seal the fistulous inlet and effectively resolve the effusion. Conclusion Precisely identifying the existing fistulous perforation and sealing its inlet can effectively reduce the need for deployment of CS.