Percutaneous management of a saphenous vein graft perforation using a covered stent and final coil embolization technique Image Ben Glover, Paul Johnston, Mark Spence Royal Victoria Hospital, Belfast, Great Britain Submitted: 23 January 2010 Accepted: 28 January 2010 Arch Med Sci 2010; 6, 6: 991-992 DOI: 10.5114/aoms.2010.19317 Copyright © 2010 Termedia & Banach A b s t r a c t Coronary artery perforation as a result of percutaneous coronary intervention is a rare complication which may result in cardiac tamponade, myocardial infarction and death. Perforation of a saphenous vein graft is unusual and generally requires surgical intervention. We describe a novel percutaneous approach that facilitated the successful management of a potentially catastrophic saphenous vein graft (SVG) perforation. Key words: vein graft perforation Coronary artery perforation as a result of percutaneous coronary intervention (PCI) is a rare complication (0.1%) [1] which may result in cardiac tamponade, myocardial infarction and death. The main predictors of coronary perforations are clinical (elderly, female gender), pharma- cological (use of glycoprotein IIb/IIIa inhibitors), angiographic (small tortuous and calcified vessels) and procedural (stiff hydrophilic wires, arte- ry to balloon ratio of > 1.2-1.3, use of atherectomy device) [1, 2]. We describe a novel approach that facilitated the successful management of a po- tentially catastrophic saphenous vein graft (SVG) perforation. A 68-year-old female treated with CABG 5 years previously was referred for PCI after angiography demonstrated a significant SVG to the first obtuse marginal (OM) lesion. At PCI (right transradial access, 6 Fr Left Coronary Bypass (LCB) guide catheter (Cordis Corporation, New Jersey, USA)) the SVG was found to be occluded. A Pilot 50 wire (Abbott Laboratories, Illinois, USA) crossed the occlusion easily and the stenosis was pre-dilated with a 2.0 mm and a 4.0 mm balloon. Contrast injection via an Export catheter demonstrated intraluminal wire position and a good sized distal OM. A 4.5 × 24 Liberte stent (Boston Scientific, Natick, USA) was deployed at 17 atmospheres resulting in a class 3 perforation (Figure 1A), tachycardia and hypotension [2]. The stent balloon was immediately positioned within the stent and inflated to control the perforation. Intravenous protamine was administered and a transthoracic echocardiogram showed a posterior pericardial effusion with compression of the posterior left atrial wall in a position almost impossible to treat with percutaneous pericardiocentesis (Figure 1B). With the inflated balloon controlling the perforation a second 8 French LCB guide catheter was introduced from the femoral artery and positioned at Corresponding author: Ben Glover, MD Royal Victoria Hospital Grosvenor Road, Belfast, BT12 6BA Phone: +44 028 9024 05 03 E-mail: ben.glover@hotmail.com