Managing Coronary Artery Perforation in a Calcified, Tortuous, and Angulated LAD

Abstract

Background: Coronary artery disease remains a leading cause of morbidity and mortality worldwide. Non-ST elevation myocardial infarction (NSTEMI) often presents with complex anatomical challenges, particularly in patients with significant coronary artery disease. Understanding the risks associated with various intervention techniques is essential for improving patient outcomes.

Case Presentation: A 78-year-old male, ex-smoker, with no known comorbidities presented with shortness of breath on exertion and chest pain classified as Canadian Cardiovascular Society (CCS) Class III. Initial evaluation on May 6, 2024, included echocardiography, which revealed an ejection fraction of 40-45% with severe hypokinesis of the apex and anterior wall. The ECG demonstrated sinus rhythm with deep T wave inversions in leads V2-V5. Coronary angiography indicated a short left main artery, a single-vessel disease with a tortuous and critically diseased proximal left anterior descending (LAD) artery, and mild disease in the right coronary artery (RCA) and dominant left circumflex artery (LCX). The patient was planned for percutaneous coronary intervention (PCI) to the LAD.

Results: During the PCI, a hydrophilic wire induced a perforation in the LAD. The lesion was subsequently crossed with a workhorse wire, and pre-dilation was performed using a semi-compliant balloon. Two drug-eluting stents (DES) were successfully placed. A relook angiogram conducted 48 hours later showed no signs of perforation and achieved TIMI 3 flow following post-dilation.

Conclusion: Coronary perforation is a recognized complication of PCI, particularly in patients with tortuous and angulated coronary vessels. While hydrophilic wires are beneficial for navigating complex anatomy, they carry a risk of dissection and perforation due to their poor tactile feedback. Careful management and monitoring during procedures involving challenging coronary anatomies are crucial for optimizing patient outcomes.