Case 216: Manual of PCI - Big one!

A patient was referred for PCI of a severe LAD in-stent lesion. The lesion was subtotal and the LAD was very tortuous with a diagonal branch originating at a proximal bend and a septal at a distal bend. Wiring attempts with multiple workhorse and polymer jacketed guidewires through various microcatheters failed. A wire was advanced in the diagonal branch and then another guidewire was advanced through a Sasuke dual lumen microcatheter into the septal. A FineCross M3 was advanced further down the LAD followed by successful wiring to the distal LAD with a Sion black wire. Several balloons, including a Sapphire 1.0 mm and a Takeru 1.5 mm balloons could not cross. Several microcatheters (Corsair, FineCross M3, MicroRx) could not cross either despite using a guide extension and side branch anchoring. Repeat wiring attempts (as the wire that crossed may have been partially outside the prior stent) failed. Use of a 0.9 mm laser led to a large perforation with tamponade and cardiac arrest. After balloon inflation proximally and pericardiocentesis with autotransfusion the patient’s hemodynamics stabilized. Attempt to deliver a PK Papyrus stent failed and wire position was lost. The patient underwent emergent cardiac surgery with bypass of the LAD and repair of the perforation site.