Ben Glover, Paul Johnston, Mark Spence A C PE LV B LA D Figure 1. A – Class 3 SVG perforation following stent deployment. B – posterior pericardial effusion with compression of left atrium. C – positioning of covered stent over site of perforation using 2 guides and a proximal balloon. D – use of coils to achieve complete occlusion of SVG perforation PE – pericardial effusion, LA – left atrium, LV – left ventricle, arrow indicates the site of the perforation the ostium of the SVG alongside the original guide, which was partially backed out of the SVG ostium. A BMW wire (Guidant Corporation, Temecula, California, USA) was passed through to the distal vessel with a brief deflation and immediate re-inflation of the balloon controlling the perforation. A 4.0 × 15 mm balloon was then advanced along this second wire and positioned and inflated in the graft proximal to the first balloon. With the second balloon in place proxi- mally, brief deflation and re-inflation allowed controlled removal of the balloon at the perforation site and deployment of a 4.5 × 19 mm covered Jostent (Abbott Laboratories, Illinois, USA) at the perforation site with minimal further flow into the pericardial space (Figure 1C). Using the same technique a 4.0 × 12 mm Jostent was deployed, overlapping with the initial covered stent. A small contrast leak persisted and coil embolization of the SVG with 4 Cook MicroNester® Embolization Microcoils™ (Cook Medical, Bloomington, USA) was performed via a microcatheter (2.4 F Progreat, Terumo [Leuven, Belgium]), achieving complete occlusion (Figure 1D). The pericardial collection resolved over 7 days. The patient remains well at six months and is currently angina free. This case demonstrates how the novel use of a proximal balloon introduced via a second guide allowed controlled removal of the balloon sealing the perforation and delivery of covered stents and coils without further catastrophic bleeding into the inaccessible posterior pericardial space. R e f e r e n c e s 1. Ellis SG, Ajluni S, Arnold AZ, et al. Increased coronary perforation in the new device era. Incidence, classification, management, and outcome. Circulation 1994; 90: 2725-30. 2. Muller O, Windecker S, Cuisset T, et al. Management of two major complications in the cardiac catheterisation laboratory: the no-reflow phenomenon and coronary perforations. EuroInterv 2008; 4: 181-92. 992 Arch Med Sci 5, October / 2010