The balloon occlusion and thrombus aspiration catheter mediated-distal coronary perfusion technique (BI-RESCUE) for treatment of coronary artery perforation

C oronary artery perforation (CAP) remains an infrequent but potentially lifethreatening complication during percutaneous coronary intervention (PCI). Although the prevalence of CAP is about 0.2%−0.9% in relatively low risk PCI, the incidence could up to 9% in complex clinical scenarios such as severe coronary calcification, chronic total occlusions and rotational atherectomy. Despite the new techniques and equipment had lower morbidity and mortality, up to 17% of acute CAP cases would evolve to tamponade and subsequent death. Ellis, et al. classified coronary perforation into three types: Type I, extraluminal crater without extravasation; Type II, pericardial or myocardial blushing; and Type III, perforation ≥ 1 mm diameter with contrast streaming or cavity spilling. In terms of Ellis type I and II CAPs, it is generally considered as a benign condition; however, Ellis type III CAP is usually more severe, with respect to need for urgent pericardiocentesis, emergent cardiac surgery and with higher mortality as compared with type I and II CAPs. Generally accepted treatments for CAP include prolonged balloon inflation, reversal of anticoagulation, covered stents and embolization. For Ellis type III CAP specifically, occurring in large coronaries involving proximal and mid segments, prolonged balloon inflation is a initially treatment, but it often causes myocardial ischemia. A perfusion balloon catheter is useful when performing prolonged balloon inflation to minimize ischemia. However, this equipment is not available in many countries, and even if available, it is difficult to stock the full range of sizes in individual hospitals. In the current case study, we report for the first time one case of successful closure of Ellis type III CAP with balloon occlusion and thrombus aspiration catheter mediated-distal coronary perfusion technique, which allows prolonged balloon inflation without causing myocardial ischemia and provides a novel method for management of lager and proximal CAP. Written informed consent was obtained from patient for this case study. A 65-year-old man was admitted to the First Affiliated Hospital of Harbin Medical University with a ten days history of paroxysmal chest pain. An electrocardiogram revealed T wave inversion in the anterior chest leads, and high-sensitivity troponin I increased to 106.5 ng/mL (reference range: ≤ 0.034 ng/mL). Coronary angiography via radial approach showed long and critical stenosis in the ostial and middle segment of the left anterior descending artery (LAD) with significant ostial stenosis of the second diagonal artery (D2) (Figure 1A & 1B). There are middle stenosis in the distal segment of the left circumflex artery (LCX) (Figure 1A & 1B) and a severe stenosis in the proximal segment of posterior descending artery (Figure 1C). A 7Fr BL3.5 guiding catheter (Terumo, Tokyo, Japan) was engaged in the left coronary artery via right femoral access. Three workhorse guidewires (Sion, Asahi, Tokyo, Japan) were positioned in the LAD, LCX and D2 arteries respectively. After predilation Journal of Geriatric Cardiology