PMC8083031_01
Contrast-enhanced echocardiography to rule-out active intrapericardial bleeding following coronary artery perforation. A. Critical stenosis of the ramus intermedius. The arrowhead points at the site of the stenosis; B. Ellis type 3 coronary artery perforation (CAP). The arrowheads point at the site of the perforation, while the asterisk marks contrast extravasation into the pericardial space; C. Ping-pong technique to achieve balloon occlusion and subsequent CAP embolization. The arrowhead points at the balloon inflated proximally to the CAP through the first guiding catheter. The arrow points at the microcatheter and guidewire through the second guiding catheter. Red asterisk: guiding catheter via the left radial access; white asterisk: guiding catheter via the right femoral access; D. Coil deployment in the ramus intermedius. Arrowheads: microcatheter. Arrow: coil; E. Complete deployment of the coils and complete sealing of the CAP; F. Second-look coronary angiography, showing no active bleeding from the CAP; G. Transthoracic contrast-enhanced echocardiogram (4-chamber view), showing no contrast in the pericardial space (arrows); H. Transthoracic contrast-enhanced echocardiogram (right ventricle-focused 4-chamber view), showing no contrast in the pericardial space (arrows).
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A 66-year-old man underwent percutaneous coronary intervention on a stenosis of the ramus intermedius for worsening dyspnea and positive exercise testing (Fig. 1A). Upon subsequent contrast injection, an Ellis type 3 coronary artery perforation (CAP) was observed (Fig. 1B). A right femoral artery access was secured, and a second guide catheter engaged the left coronary artery (ping-pong technique) (Fig. 1C). Three 3-mm MicroNester 18 (Cook Medical, Bloomington, Indiana) coils were delivered to seal the perforation through the second guide catheter (Fig. 1D, E). CAP (Fig. 1F). Contrast-enhanced TTE was performed after intravenous injection of 10 mL of sodium hexafluoride-based ultrasound contrast (SonoVue, Bracco Imaging, San Donato Milanese, Italy). No evidence of contrast in the pericardial space was detected in our patient, ruling out active bleeding (Fig. 1G, H).