CASE20210828_001

Accidental STAR with Ellis III Perforation in VF Arrest Primary PCI

By Jonathan Fang Jonathan Fang
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Presenter

Jonathan Fang

Authors

Jonathan Fang Jonathan Fang1

Affiliation

Queen Mary Hospital Hong Kong, Hong Kong, China1
Complications - Complications

Accidental STAR with Ellis III Perforation in VF Arrest Primary PCI

Jonathan Fang Jonathan Fang1

Queen Mary Hospital Hong Kong, Hong Kong, China1

Clinical Information

Patient initials or Identifier Number

DB

Relevant Clinical History and Physical Exam

64 year-old man collapsed on the street with bystander CPRFound to be VF arrest. Defibrillation on ambulance 5 timesRefractory VF with ECMO inserted at the emergency department and commenced E-CPR with established 45 minutes after onset of symptomEcho LVEF 25% global hypokinesiaSent to Cath lab for primary PCI

Relevant Test Results Prior to Catheterization

ECG RBBB and diffuse TWI 

Relevant Catheterization Findings

pRCA occluded LM-LAd 40% dsLCx ostial CTO. OM filled by L->L collaterals 

Interventional Management

Procedural Step

VA ECMO via RFA RFV
LFA 6Fr access. JR4 guide
Sion Blue GW encountered difficulty when wiring. Wired with knuckling 
p-mRCA predilation with 3.0/12 balloon followed by thrombus aspiration with penumbra for 2 passes
pRCA stent with 4.0/38 DES at 12atm and postdilate with 4.0x15 NC balloon at 12atm 
Noted filling defect distal to stent. IVUS done followed by stent with 4.0x22 DES at 10atm

Post stenting noted Ellis class 3 perforation at stent overlap segment. Immediate balloon tamponade followed by reassessment after 15 and 30 imnutes. Persistent extravasation. Cover stent (PK Papyrus) 4.5 x 20m and 3.5x 15 followed by further balloon occlusion.  Pericardiocentesis done with access with micropuncture set with 0.18 peripheral wire and upsizing to pericardiocentesis set. Further balloon occlusion with 4.0 stent balloon. No further extravasation

IVUS showed that the p-dRCA segment was actually in the suboptimal space and there was subintimal tracking with disseciton-reentry ( STAR) in distal RCA PDA/PL bifurcation. 

Case Summary

In acute cardiac arrest setting with primary PCI, inadvertent wiring into subintimal space could occur

Intra-vascular imaging is important for troubleshooting

Consider downsizing when in subintimal space