PMC3262528_01
(a) Left anterior oblique projection demonstrating right coronary artery (RCA) stenosis and stent implantation. Right ventricular branch (side branch (SB)) emanates from the stenosed region. (b) contrast leakage through a relatively large hole into the pericardium after stent deployment. (c) contrast leakage is reduced markedly after immediate and prolonged balloon inflation. (d) complete cessation of contrast extravasation after polytetrafluoroethylene- (PTFE-) covered stent implantation with occlusion of the SB. (e) followup angiography of the RCA 4 months later reveals moderate instent restenosis and regrowth of the SB occluded by the PTFE-covered stent.
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fig1
The stenosis was dilated with an undersized balloon followed by implantation of a bare-metal stent-type driver 4.0 x 24 mm with a pressure of 14 atmospheres (Figure 1(a)). This resulted in acute right coronary perforation and profound dye (blood) extravasation (Figure 1(b)). The immediate and prolonged balloon inflation reduced the dye extravasation markedly (Figure 1(c)) and prevented development of cardiac tamponade. This successfully sealed the perforation with complete cessation of dye extravasation and restoration of normal anterograde flow (Figure 1(d)). Followup angiography of the RCA four months (Figure 1(e)) and, because of increasing dyspnea, 11 months after the incident showed a moderate instent restenosis at the proximal and distal edges of the covered stent. To our surprise, the SB was recanalized after occlusion by the PTFE-covered stent (Figure 1(e)).
Intravascular ultrasound (IVUS) (a) shows moderate hyperplasia of the intima and well-apposition of the PTFE-covered stent to the first implanted stent. Right coronary angiography in caudal left anterior oblique (b) and in right anterior oblique projection (c) shows the channel between the right coronary artery and the side branch. Both IVUS and right coronary angiography were done 11 months after the incident.
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fig2
The SB and its ostium could not be seen by IVUS (Figure 2(a)). The channel begins at the distal end of the covered stent and continues upward retrogradely toward the SB ostium filling the SB (Figures 2(b) and 2(c)).