Case 170: Manual of PCI - Covered stent did not work

A patient was referred for PCI of the right coronary artery and the LAD. The RCA had a severe, heavily calcified distal lesion. Equipment delivery to the RCA lesion failed through radial access despite using a guide extension. After changing to femoral access with an 8 French AL1 guide and a guide extension a balloon could be delivered to the RCA lesion but the lesion was balloon undilatable. The lesion expanded after high-pressure inflation with a NC balloon but the balloon ruptured causing a dissection/perforation. The patient remained hemodynamically stable and echo showed a small pericardial effusion. There was no improvement after placing a drug-eluting stent. A 3.5x26 mm PK Papyrus covered stent was delivered decreasing but not eliminating the extravasation. Eventually the perforation was sealed after a 2nd PK Papyrus stent was delivered and deployed more proximally in the lesion.

[@narendhiranpandurangan684]

We are lucky to have teachers like you and the technology to access it as well

[@shangz0216]

We are deeply indebted to you for your excellent case presentation.

[@amitchaturvedi7906]

Sir few observations :
1. From Radial access a 7 F Terumo glider sheath with 0.75 AL could have been taken upfront followed by guideliner support
2. Since there was calcification in distal RCA on angiogram, an IVUS run could have been taken to see the presence of a calcific nodule!
But the case was a good learning experience!
Forever indebted for your teaching 🙏

[@georgetouma5430]

Bill Lombardi has taught me never to inject near the perforation with a guide extension buried in the vessel as it promotes expansion.
I had a very difficult case where the covered stent didn’t work upfront likely due to this. In our case a DES was required within the covered stent as we didn’t have second stent.

[@nadermakki-l5q]

While its always 20/20 in hindsight, Why not do upfront rota femoral as it is heavily calcified and or IVL?
This will obviate the need for high pressure PTCA and may have avoided the perf

[@denizaktürk-j7n]

Deploying a longer noncovered stent in the covered stent helps to make endothelisation faster? It may also keep edges of covered stent on the vessel wall and well apposed

[@johnwilson7660]

I wonder if coronary dcbs could be used for tamponade. You would have the benefit from the drug since you're already doing a prolonged inflation.
I wonder if the open strut design of the des allowed flow between the vessel wall and the covered stent. If so, would you need to make sure you covered both ends?
Some covered stents, like the viabahns, have little holes near the ends. I wonder if the papyrus or graft masters have something similar.

[@qahtanqashour8990]

Thanks

[@NikhilJha89]

Why des when already there was perforation?
Straight up atherectomy could have been a better choice in hindsight?

[@MinorityDoc]

Cutting balloon is the way to go. Else undersize the balloon by 0.25 to prevent perf. Greatly indebted to you

[@denizaktürk-j7n]

May deploying a longer stent in graft stent? This may keep the edges of covered stent.

[@denizaktürk-j7n]

And in predilatation with N.C what is the balloon to vesselam ratio? Is lowering the diameter and increasing the pressure logic?

[@mahmoud_elrayes]

Excellent save. What is the direction of contrast jet of ruptured balloon, radial force in the largest diameter of balloon or longitudinal (proximal/distal) or both? Thanks

[@mahmoud_elrayes]

Another question , does increasing the inflation pressure above the nominal pressure of PK Papyrus (8 atm for 2.5-3.5 mm stents and 7 atm for 4.0-5.0mm stents) expose the polyurethane membrane to disruption? Thanks.

[@arhipmatusov8823]

That's why I'm still so skeptical about so called "zero contrast PCI"... :)

[@jadenlee3379]

Is it possible to prevent the rupture if shorter balloon has been used?