Conservative approach to managing coronary perforation during retrograde chronic total occlusion percutaneous coronary intervention: a case report

Background: Coronary artery perforation is a highly feared complication of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) and can lead to pericardial effusion, tamponade, and, rarely, emergent cardiac surgery. Perforation of coronary artery or epicardial collaterals during retrograde CTO-PCI may be particularly challenging to treat, as embolization from both sides of the perforation may be required to control the bleeding. However, only conservative measures in selected cases can be effective. We report a case of distal posterior descending (PD) branch of left circumfl ex (LCX) artery vessel perforation that was managed conservatively with anticoagulation reversal. Case Summary: An 85-year-old Caucasian male patient, with a history of lateral and inferior myocardial infarction and previous PCI, underwent a planned coronary arteriography due to progressive angina. Coronary angiography revealed normal function of implanted drug eluting stents (DES) in the mid-LAD and in the proximal right coronary artery (RCA) and CTO of dominant LCX. A septal branch in the midsegment of LAD was supplying the distal PD of LCX retrogradely. After failed attempt at antegrade PCI for the LCX’s CTO, the retrograde approach was tried. This intervention fi nally succeeded through the septal collateral but after removing the retrograde guidewire with the support of microcatheter, vessel perforation of distal PD of LCX was observed. This complication was successfully managed conservatively with anticoagulation reversal. Post-operatively, the patient had no complications and was stable at 6-month follow-up. Discussion: Coronary artery perforation can be managed conservatively only with anticoagulation reversal in selected cases.