Coronary artery perforation during primary PCI: an easily resolved case for a dramatic complication

A 55-year-old male diabetic and hypercolesterolemic patient presented with acute lateral wall myocardial infarction. Coronary angiography showed a significant stenosis of distal right coronary artery (RCA), a total chronic occlusion of a small left circumflex, and the left anterior descending (LAD) and acute coronary occlusion of the first marginal branch (MB) (Panel A). The patient underwent MB primary angioplasty (Panel A). The patient was treated with 300 mg of clopidogrel and 8000 I.U. of heparin. The MB occlusion was crossed with guide wire, and pre-dilatation was performed using 2.0 × 15 mm balloon (Maverick, Boston Scientific). Just after a Janus stent (2.75 × 25 mm, Sorin) deployment, there was angiographic evidence of coronary perforation (type III of Hellis-Classification) (Panel B). At that moment, we inflated a balloon (3.0 × 12 mm, Aria-Sorin) at the perforation site, giving neutralization therapy with protamin (55 mg) towards the heparin effect (activated clotting times 165 s). We inflated the balloon five times, 5 min each inflation. The control angiogram showed a closure of the site of perforation and a final TIMI-III flow and MBG-II (Panel C). The patient, asymptomatic and hemodynamically stable, was admitted to the intensive care unit with aspirin (100 mg), clopidogrel (75 mg), atorvastatin (20 mg) and insulin. After 2 days, another coronary angiography was performed to complete the procedure for LAD disobstruction and RCA angioplasty. During this procedure, we performed an intravascular ultrasound for the control of the MB (Panel D) that showed the site of perforation well repaired and haematoma behind the proximal part of the stent deployed in the MB. The patient was discharged after 5 days as asymptomatic and haemodynamically stable.