PMC4054828_01
Diagnostic angiograms showing severe in-stent restenosis in Major OM stent.
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Coronary angiogram done this time revealed severe in-stent restenosis (ISR) of OM and patent stents to LCX and LAD (Fig. 1).
A- Slight bulge in contour (black arrow) seen at distal end of stent post dilatation. B- Progression to Ellis grade III perforation.
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The angiogram done immediately post final balloon dilatation now showed a small bulge in contour (Fig. 2A), which quickly progressed to complete rupture (coronary perforation grade 3, Fig. 2B) with the immediately following injection showing torrential leak into the pericardial space.
A- Covered stent Graft-master 3 x 16 mm deployed. B- No residual leak from perforation site.
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Immediate attempt to seal the perforation site with a covered stent, Graft-master (Abbott Vasc, USA) 3 x 16 mm was made with successful closure of the leak and containment of the cause (Fig. 3A and B).
Check angiogram showing jet of contrast from tip of ramus (Black arrow) and no leak from covered stent site (white arrow).
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Angiogram however revealed that previous perforation site was well sealed with the covered stent and, to our surprise, there was torrential leak of blood from distal end of a small ramus like vessel, an artery which had not been worked upon anytime during the procedure (Fig. 4A and B) and the cause of this leak was in a way unexplained.
A- injection of sterile intra-arterial glue mixed with lipiodol into small ramus (black arrow). B- Complete occlusion of small ramus (Black arrow).
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The tiny ramus vessel occluded instantaneously at mid level with immediate stoppage of the leak into the pericardium (Fig. 5A and B).