Distal Coronary Perforation Managed with a Cut Balloon Tip
Dr Ashish Trivedi*
KEM hospital Pune, Maharashtra, India
Submission: November 01, 2023; Published: November 24, 2023
*Corresponding author: Ashish Trivedi, KEM hospital Pune, 1202,subhash Nagar, Maharashtra, India
How to cite this article: Dr Ashish T. Distal Coronary Perforation Managed with a Cut Balloon Tip. J Cardiol & Cardiovasc Ther. 2023; 19(1): 556001. DOI: 10.19080/JOCCT.2023.19.556001
Keywords: Coronary artery; Hypokinesia; Cardiac tamponade; Pericardial effusion
Introduction
Coronary artery perforation is a rare but life-threatening complication of percutaneous coronary interventions [1]. Cardiac perforation is a serious complication resulting in pericardial tamponade, which requires immediate intervention. Treatment options for coronary perforation typically involve the utilization of different techniques such as covered stents, coil deployment, and glue embolization. The present case report highlights the successful management of a distal coronary perforation using a novel approach involving the use of a cut balloon tip used to seal the perforation. I We encountered a patient with a distal coronary perforation during a percutaneous coronary intervention. The perforation occurred when the Fielder FC guide wire inadvertently punctured the vessel wall. This complication posed a significant risk to the patient’s life and required immediate attention.
Clinical Examination Findings
A 45-year-old male patient presented with chest discomfort in the last 24 hours and was diagnosed with an evolved inferior myocardial infarction. The troponin I levels were significantly increased.

Diagnostic Tests and Results
2 Echocardiography showed inferior-posterior wall hypokinesia and a left ventricular ejection fraction of 45%. Based on the findings during coronary angiography, it was observed that there were multiple planes of dissection/ fragmented thrombus in the right coronary artery. The distal right coronary artery was filling retrogradely from the left system. His left anterior descending and left circumflex arteries were normal. Intravascular ultrasound done confirmed the presence of fragmented thrombus & significant stenosis in the RCA (Figure 1 & 2).


Proposed Approach for Treatment
Patient was advised to undergo coronary angioplasty; the right coronary artery was cannulated using a 3.5 Judkins right guiding catheter and wired with a Fielder FC guide wire. The lesion in the RCA was then stented with three overlapping stents from the posterior descending artery (PDA) to the proximal RCA. We achieved successful stent expansion and observed TIMI III distal flow. However, we identified a perforation at the far end of the PDA. Initially, we performed balloon dilatation in the PDA using a 2.5 x 15 mm balloon for approximately 7-8 minutes, but subsequent imaging showed sustained leakage of contrast from the PDA. Another round of balloon inflation was attempted, but there was persistent leak. Due to the unavailability of coils or glue during the procedure and given that the artery size was too small to accommodate a covered stent, our approach for managing this distal coronary perforation involved inserting a guide-plus catheter with balloon support into the distal RCA. Subsequently, we cut and mounted a 1.5 x 10mm balloon tip with a little part of the shaft on a guide wire as; it was then pushed inside using a 2.5 x 15 mm balloon delivery system. Afterward, we retracted both balloon delivery systems along with the guide wire, leaving the cut balloon tip in the distal part of PDA. A follow-up check shoot confirmed the successful sealing of perforation. The patient was hemodynamically stable, on echo screening there was no significant pericardial effusion or cardiac tamponade. The patient was observed in the critical care unit for 48 hours & discharged after 2 days (Figure 3 & 4).

Discussion
This was an urgent effort to close the perforation since we didn’t have any micro coils or gelatin swab. Since we had already placed 3 stents, we decided not to use protamine. We used a guide plus catheter for added stability when delivering the cut balloon tip, ensuring that there would be no risk of disengagement or embolization. It is crucial to closely monitor the long-term results of this procedure. The novel approach used in this case successfully sealed the perforation of the distal coronary artery when conventional methods such as prolonged balloon inflation were ineffective. However, it is essential to consider alternative perspectives and approaches when managing distal coronary perforations. While the use of a guide-plus catheter with a cut balloon tip may have been successful in this case, it is worth exploring other options that have been reported in the literature (Figure 5). The use of vascular occlusion materials such as micro coil or gelatin sponge in cases of distal coronary artery perforation is commonly used. By utilizing these occlusion materials, it may be possible to achieve effective hemostasis without the need for improvising, but we thought of sharing this approach as it proved to be lifesaving in desperate situation. & can rarely be used as bail out strategy. The long-term outcome needs to be monitored closely.
