How Coronary Perforation Looks at Optical Coherence Tomography Imaging

Keywords: coronary intervention, coronary perforation, optical coherence tomography, PCI

A 78-year-old woman admitted for anterior non-ST elevated myocardial infarction underwent coronary angiography, which showed a critical stenosis of the proximal and distal left anterior descending artery (LAD). After predilation, the distal LAD was stented with 2 minimal overlapping drug-eluting stents (DES) (Xience Sierra 2.5 x 38 mm and 2.5 x 28 mm; Abbott). The proximal LAD was predilated and stented with 1 DES (Xience Sierra 3 x 28 mm). The patient was stable and optical coherence tomography (OCT) (Dragonfly Optis imaging catheter; Abbott) demonstrated the absence of stent edge dissections and good strut apposition in the distal LAD stent. The patient developed severe hypotension and subsequent pulseless electrical activity, which required cardiopulmonary reanimation. Angiography showed distal LAD perforation and emergent echocardiography confirmed the presence of cardiac tamponade. Immediate pericardiocentesis was performed and two covered stents (BeGraft coronary stent 3 x 16 mm and 3 x 18 mm; Bentley InnoMed GmbH) were deployed with successful closure of the perforation. The patient’s hemodynamics recovered and final angiography demonstrated no streaming of contrast. Later review of the OCT images showed that initial coronary perforation (CP) was already visible as an abrupt interruption of the intimal tissue and the presence of a crater with blood reaching the external layers of the vessel wall. CP was probably caused by overstretch of the vessel wall in an intramural segment of the LAD. CP is a possible complication of percutaneous transluminal coronary angioplasty, which is rarely documented with intracoronary imaging due to its rapid and dramatic evolution. Here we report the unique images of how an initial CP appears at OCT (Figure 1; Video 1).

Affiliations and Disclosures

From the University of Trieste, Italy.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

The authors report that patient consent was provided for publication of the images used herein.

Manuscript accepted May 27, 2022.

Address for correspondence: Enrico Fabris, MD, PhD, Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Italy, Via Valdoni 7, 34128 Trieste, Italy. Email: enrico.fabris@hotmail.it