Coronary Perforation in a Patient with ST Elevation Myocardial Infarction Treated by Stent Graft Implantation Using the Double Guide Catheter (Ping Pong) Technique

Coronary perforation can occur as a complication of Percutaneous Coronary Intervention (PCI) even in the contemporary era of new tools and techniques. Severe proximal perforation can potentially be lethal if not diagnosed or left untreated. This dreaded complication can occur due to the mismatch between the balloon and vessel size. However, it may happen with an appropriately sized balloon or stent in case of eccentric coronary calcification or negative vessel remodeling. The current study aimed to present a case of severe type III perforation, which was managed successfully using the double guide catheter technique for stent graft implantation.

A 61-year-old man with the history of stenting in the Right Coronary Artery (RCA) presented with acute inferior ST Elevation Myocardial Infarction (STEMI). Emergent coronary angiography revealed acute instent thrombotic occlusion of the RCA. After wiring, predilatation of the previous stent was carried out. Test injection showed Ellis type III coronary perforation. A 3.5*15 mm balloon was inserted promptly and was inflated at the perforation site. Right femoral artery access was obtained and a stent graft was deployed using the double guide catheter or the ping pong technique. The perforation was sealed and extravasation was ceased. Echocardiography showed moderate pericardial effusion without any sign of chamber collapse. Heparin was not reversed in order to prevent stent thrombosis. Further echocardiography 3, 24, and 48 hours after the procedure showed noticeable reduction of the pericardial fluid and the patient was discharged home in favorable conditions. He participated in regular followup visits and did well after about 18 months.

The double guide catheter technique was found to be a safe and effective method in treating Ellis type III coronary perforation.