We change the catheter for AL1 6F. We then proceed to insert 3 bare stents (REBEL: 2.5×16, 3.0×16, 3.0x16mm to 11 atm) overlapping from distal third to mid third, covering the stenotic lesion and perforation.

We perform bedside transthoracic echocardiogram that shows mild to moderate pericardial effusion with no collapse of right cavities.

We perform hemostasis at rupture site of DA with balloon 3.0x16mm to 8 atm in 6 opportunities, 2 minutes each.

Control angiography: patent DA, residual stenosis 0%, with no contrast leak.

We observe adequate result. We retrieve the inductor.

Control at ICU after 24 hrs.

Hemodynamically stable patient with no inotropic drugs, KK1, with no pericardial rub, tolerates decubitus.

ECG: T+/- precordial, lack of R progression.

ICU at 48hrs:

Spontaneous AF with RVR: patient is given digoxin and reverts to sinus rhythm.

ICU at 72hrs:

Echocardiogram:

VI: conserved diameters and thickness, left atrial mild dilation. Moderate extended hypokinesia in anterior and septal anterior walls. 49% EF with mild systolic dysfunction.

Diastolic G2 dysfunction, left ventricle with pseudo-normal filling pattern. E/a 18 (average). RVSP 43mmHg. Right cavities with conserved dimensions and functions. Valves S/P.

Mild posterior pericardial effusion.

We focused on 2 points of interest:

1. Failure to deflate:

a. CAUSE: failure to deflate a coronary balloon is extremely rare when using new material. This might happen when using reprocessed and resterilized material. Therefore, it is essential to check correct inflation/deflation before introducing second-hand balloons. The presence of a foreign body in the inflation hypotube, such as a remaining contrast crystal, could have been the cause. The “valve effect” created by such material would allow balloon inflation, but not deflation. Another mechanism could have been a twisted hypotube, even though this is more common in Inoue like balloons, in mitral valvuloplasty. 

b. SOLUTION: How can we act to achieve balloon deflation without further iatrogenic injury? Insufflation pressure superior to that of balloon rupture should be the first choice. This was done in this case, but without causing the balloon to burst, but rather causing overdilation distal to the tube connecting with the balloon and its resulting explosion. This generated coronary rupture.

2. “Coronary rupture”:

a. When treating a coronary rupture the first thing should be to define the type of rupture we are facing. Correct effusion classification will help us make the best choice, always on a case by case basis. The current classification, which extended to 5 categories the original S. Ellis classification, offers a comprehensive view for the diagnosis and management of this complication.

b. In this case, we have a type 3 rupture, since there is free extravasation of contrast into the pericardium. Even though the available dynamic image does not show this neatly enough, we can appreciate the left ventricle silhouette is separated from the pericardial contour, and a dark area of pericardial fluid because of the contrast dilution.

c. The rupture management algorithm shows a type 3 rupture requires the following measures: 

• i. Neutralizing heparin
• 1.  
• ii. Insufflating an occlusion balloon at low pressure in the rupture area
• iii. Immediate access to echocardiogram
• iv. Alerting cardiac surgery
• 1.  
• v. Hemodynamics monitoring and stabilizing
• vi. Preparing maneuvers for eventual pericardial drainage
• vii. Checking availability of coated stent according to anatomy; be ready to use it in case of failure of the above stated
• viii. In case of failure to control the rupture within a sensible timeframe with the available resources, resort to emergency surgery procedure.

In this case, the complication was successfully solved with bare stent implantation (3) to lesion/rupture site and keeping vessel patency. 

FINAL MESSAGE:

As a major takeaway, this case makes us reflect upon 2 aspects:

• When using reprocessed and resterilized material, quality control processes should be exhaustive and extreme at the precise time of use. 
• In a modern cath lab, coated stents must always be available, since they will allow us to treat severe complications simply and effectively. 

Congratulations to Dr. Pablo Solivellas for sharing this interesting case, to Drs. Lazarte, Rippa, Caprotta, Miara and Lopez Marinaro for their comments and to Dr. Nicolás Zaderenko for his initiative to support this exchange initiative at SOLACI.

Dr. Jorge Mayol
Ex Director of SOLACI SESSIONS
Co-Director of the Hemodynamics Service at the American Cardiology Center of the American Hospital in Montevideo, Uruguay