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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 8  |  Issue : 3  |  Page : 158-161

Role of optical coherence tomography in a case of coronary perforation


Department of Cardiology, Aayush Hospitals, Vijayawada, Andhra Pradesh, India

Date of Submission01-Mar-2020
Date of Decision07-Jun-2020
Date of Acceptance24-Jun-2020
Date of Web Publication26-Nov-2020

Correspondence Address:
Dr. P S S Chowdary
Department of Cardiology, Aayush Hospitals, Vijayawada - 520 002, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/heartindia.heartindia_9_20

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  Abstract 


Coronary angiography is the gold standard imaging modality during coronary interventions, but coronary angiogram has many limitations, catheter-based imaging modalities such as optical coherence tomography (OCT) have the potential to overcome these limitations, it plays a role in planning the procedure before stent implantation, it helps in optimizing the stent postprocedure and detecting mallapposition, edge dissection, but its role in coronary perforation has not been established in the literature, this is the first case reporting the OCT findings in a case of coronary perforation. This case highlights the fact that contained perforation can be diagnosed with the help of OCT, complimenting the coronary angiogram.

Keywords: Coronary angiogram, coronary artery disease, electrocardiogram, left anterior descending artery, left circumflex, optical coherence tomography, percutaneous coronary intervention, right coronary artery


How to cite this article:
S Chowdary P S, Subrahmanya Sarma VR, Palaparthi R, Somasekhar G, Gopalakrishna K, Rao K P, Boochibabu M, Prasad M, Sasidhar Y. Role of optical coherence tomography in a case of coronary perforation. Heart India 2020;8:158-61

How to cite this URL:
S Chowdary P S, Subrahmanya Sarma VR, Palaparthi R, Somasekhar G, Gopalakrishna K, Rao K P, Boochibabu M, Prasad M, Sasidhar Y. Role of optical coherence tomography in a case of coronary perforation. Heart India [serial online] 2020 [cited 2021 Jan 21];8:158-61. Available from: https://www.heartindia.net/text.asp?2020/8/3/158/301599




  Introduction Top


Coronary artery disease (CAD) is one of the most common cardiovascular diseases in the elderly population.[1] Percutaneous coronary intervention (PCI) has become the mainstay invasive therapy for CAD patients.[2] Coronary angiogram (CAG) is the gold standard for imaging during coronary interventions, but CAG has many limitations, catheter-based intravascular imaging modalities such as optical coherence tomography (OCT) have the potential to overcome these limitations and optimize the coronary intervention in the form of detecting stent malapposition, suboptimal stent deployment, thrombus, tissue prolapse, and edge dissection.[3],[4] However, its role in coronary perforation has not been described in the literature previously; here, we describe a rare case of OCT being done in a case of coronary perforation.


  Case Report Top


A 74-year-old gentle man, who is known hypertensive, had a history of CAD, he underwent PCI to Left circumflex (LCX) in 2003, again in 2014 he underwent PCI to left anterior descending artery (LAD), mid Right coronary artery (RCA), failed attempt to distal Right coronary artery (RCA). He again presented in 2018 with effort angina; echo showed a normal left ventricular function, with no electrocardiogram changes, and his troponins were normal, after being stabilized CAG done, showing patent LAD, LCX, RCA stents, and a critical lesion in distal RCA [Figure 1]. After discussing the merits of the intervention, the patient consented for PCI to distal RCA.
Figure 1: Coronary angiography showing critical distal right coronary artery lesion, patent left anterior descending artery, left circumflex, mid right coronary artery stents

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RCA lesion was wired with Sion blue wire, the lesion was predilated with 1.5 NC, 2.5 NC balloons at high atmospheres, at this stage, OCT was done, it showed circumferential calcium in the distal RCA, [Video 1] options of doing a rotablation were negated, and the lesion was again predilated with 2.5 Nc balloon to 26 atm, and it was stented with 2.5 × 38 EES at 12 atm, keeping a wire in PDA, removing the wire created an LSD which was promptly recognized, corrected by post dilating with a 3 NC balloon at 18 atm. OCT done at this stage showed that the stent is under expanded because of the circumferential calcium, hence again, the stent was post dilated with 3 NC balloon at 26 atm, this resulted in Ellis type 3 free coronary perforation [Video 2]. It was treated with repeated low-pressure balloon inflation with 3 × 10 balloon at 8 atm, it resulted in conversion of a free perforation into a contained perforation. As the patient is hemodynamically stable, echocardiogram not showing any pericardial effusion, OCT imaging was done which also confirmed that the perforation is a contained perforation [[Figure 2], [Figure 3] and Video 3]; hence, the covered stent was not implanted. A 3.5 × 48 EES was implanted in mid-RCA at 12 atm, post dilated with a 3.5 NC balloon at 12–18 atm with good results [Figure 4], the patient was kept on dual antiplatelets, and till now, the patient completed 1-year follow-up without any further events.
Figure 2: Optical coherence tomography images showing the contained perforation

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Figure 3: (a) pre procedure optical coherence tomography image showing severe concentric calcium in the distal right coronary artery, (b) optical coherence tomography run of the distal right coronary artery, after balloon dilation, (c and e-g). Optical coherence tomography run showing a contained perforation, after an Ellis type 3 perforation being treated with prolonged balloon inflation. d. Final coronary angiogram showing a contained perforation in distal right coronary artery

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Figure 4: Final result showing a good result with a contained perforation

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  Discussion Top


Coronary perforation is a potentially serious and dreaded complication which occurs in 0.1%–0.6% of cases undergoing PCI,[5],[6],[7],[8],[9] it may lead to pericardial effusion, often cardiac tamponade which is often fatal when undiagnosed and untreated. Coronary perforation is associated with risk factors related to the clinical features, the anatomy, and the technical approach, such as older age, female gender, chronic total occlusions, calcified lesions, significant tortuosity, use of high postdilation pressures, larger balloon size (balloon-artery ratio >1.2)[10],[11] to optimize the angiographic result, and angioplasty in vessels with significant loss of distal caliber (tapering).[10],[11] Another common cause for perforation is guide wire exit,[6] hydrophilic-coated guide wire may increase the risk of perforation because they easily migrate to the distal portion of the vessel.[12] The use of atheroablation devices predisposes to this complication at higher frequency (1% vs. 0.2% when they are not used).[10] Here, in our case, coronary perforation occurred due to the aggressive optimization of the stent to higher pressure. Although studies done by Thomson et al.[12] showed that the type 3 coronary perforation is better managed with a covered stent, in the present case, the as the patient had stable hemodynamics, without any percardial effusion, it being a contained perforation, covered stent was not used.

In 1994 Ellis et al[5] was the first to report classification of coronary perforation in PCIs and high incidence of major adverse events. In that study, the authors also proposed a classification of perforations, which is used to date: Type I, extraluminal cavity without contrast extravasation (8% risk of tamponade); Type II, presence of pericardial blush and myocardium without contrast extravasation (13% risk of tamponade); type III, contrast extravasation through outflow tract orifice >1 mm (up to 63% risk of tamponade); and type IV, perforation draining into a heart chamber or coronary sinus (cavity spilling).

CAG has low-to-moderate sensitivity compared with grayscale intravascular ultrasound (IVUS) or OCT in the assessment of intracoronary calcium. The OCT is considered as the gold standard for coronary calcium detection.[13] In a recent in vitro study, IVUS did not detect calcium in 14.8% of segments containing histopathologic calcium; reasons included microcalcium deposits (9.4%) and deep calcium hidden behind a large necrotic core that produced echo attenuation (5.4%).[14] With OCT, calcium appears as a signal-poor or heterogeneous region with sharply delineated leading, trailing, and/or lateral borders. Unlike IVUS, penetration of calcium by OCT is greater than for other tissue types which makes OCT more suitable to measure calcium thickness, area, and volume, and automatic quantification.[15] In the present case, OCT helped in identifying the circumferential calcium in RCA, as calcium is predominantly in distal RCA, rotaablation was not done.

OCT can be used to provide a detailed analysis of the coronary artery wall, including plaque characterization, thincap fibroatheroma and vulnerable plaque identification, and assessments of the vascular response to PCI, which may be responsible for acute coronary events. Its role in coronary perforation has not been established; usually, patients with coronary perforation would be hemodynamically unstable and condition may not permit to do an OCT imaging. In contrast, the present case shows that OCT complements the angiography to know whether the perforation is contained or not.

In the long term, these contained perforations may present as coronary artery pseudoaneurysms/aneurysms. The exact pathophysiology causing them remains unknown, many are believed to be caused by traumatic injury to the arterial wall [16], infection [17] and complex inflammatory or hypersensitivity triggering incomplete endothelization, after Drug eluting stent (DES ) implantation.[18] A study done by Vijay et al[19] showed that coronary artery aneurysms occurring after the coronary intervention are rare in the current era of biodegradable polymer stents. The reported incidence of these aneurysms varies from 0.3% to 4% in various Drug eluting stent (DES) versus bare metal stent (BMS) randomized trials and few case series. Clinical spectrum and time frame of presentation of these aneurysms remain widely variable as some are asymptomatic, others may present as an acute coronary event. Hence, our patient was kept on dual antiplatelets even after 1 year of intervention.


  Conclusion Top


Coronary perforation is the most lethal complication after PCI; the present case shows that Ellis type 3 coronary perforation can be managed without a covered stent, especially in the case of a contained perforation. OCT complements angiography in the diagnosis of a contained perforation.

Acknowledgement

The authors would like to acknowledge the fact that these data are the original research data, they has not been published in any journal. In addition, the authors would like to thank the Aayush Hospitals for their contribution of data.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Authors' Contributions

Chowdary PSS - Final approval of the version to be published. Venkata RS Subrahmanya Sarma - Conception or design of the work, Data collection, critical revision of article. Raghuram Palaparthi - Drafting the article Somasekhar G - Critical revision of article. Gopalakrishna K - Critical revision of article Purnachandra rao K - critical revision of article Boochibabu M - Critical revision of article. Prasad M - critical revision of article. sasidhar Y - Critical revision of article.

Ethical Approval

This case report is sent for publication after attaining approval from Aayush hospitals ethics committee.



 
  References Top

1.
Ehara S, Hasegawa T, Nakata S, Matsumoto K, Nishimura S, Iguchi T, et al. Hyperintense plaque identified by magnetic resonance imaging relates to intracoronary thrombus as detected by optical coherence tomography in patients with angina pectoris. Eur Heart J Cardiovasc Imaging 2012;13:394-9.  Back to cited text no. 1
    
2.
Lin GA, Dudley RA, Lucas FL, Malenka DJ, Vittinghoff E, Redberg RF. Frequency of stress testing to document ischemia prior to elective percutaneous coronary intervention. JAMA 2008;300:1765-73.  Back to cited text no. 2
    
3.
Gonzalo N, Serruys PW, Okamura T, Shen ZJ, Onuma Y, Garcia-Garcia HM, et al. Optical coherence tomography assessment of the acute effects of stent implantation on the vessel wall: A systematic quantitative approach. Heart 2009;95:1913-9.  Back to cited text no. 3
    
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Kawamori H, Shite J, Shinke T, Otake H, Sawada T, Kato H, et al. The ability of optical coherence tomography to monitor percutaneous coronary intervention: Detailed comparison with intravascular ultrasound. J Invasive Cardiol 2010;22:541-5.  Back to cited text no. 4
    
5.
Ellis SG, Ajluni S, Arnold AZ, Popma JJ, Bittl JA, Eigler NL, et al. Increased coronary perforation in the new device era. Incidence, classification, management, and outcome. Circulation 1994;90:2725-30.  Back to cited text no. 5
    
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Gruberg L, Pinnow E, Flood R, Bonnet Y, Tebeica M, Waksman R, et al. Incidence, management, and outcome of coronary artery perforation during percutaneous coronary intervention. Am J Cardiol 2000;86:680-2, A8.  Back to cited text no. 6
    
7.
Dippel EJ, Kereiakes DJ, Tramuta DA, Broderick TM, Shimshak TM, Roth EM, et al. Coronary perforation during percutaneous coronary intervention in the era of abciximab platelet glycoprotein IIb/IIIa blockade: An algorithm for percutaneous management. Catheter Cardiovasc Interv 2001;52:279-86.  Back to cited text no. 7
    
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Gunning MG, Williams IL, Jewitt DE, Shah AM, Wainwright RJ, Thomas MR. Coronary artery perforation during percutaneous intervention: Incidence and outcome. Heart 2002;88:495-8.  Back to cited text no. 8
    
9.
Stankovic G, Orlic D, Corvaja N, Airoldi F, Chieffo A, Spanos V, et al. Incidence, predictors, in-hospital, and late outcomes of coronary artery perforations. Am J Cardiol 2004;93:213-6.  Back to cited text no. 9
    
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Witzke CF, Martin-Herrero F, Clarke SC, Pomerantzev E, Palacios IF. The changing pattern of coronary perforation during percutaneous coronary intervention in the new device era. J Invasive Cardiol 2004;16:257-301.  Back to cited text no. 10
    
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Cohen BM, Weber VJ, Relsman M, Casale A, Dorros G. Coronary perforation complicating rotational ablation: The U.S. multicenter experience. Cathet Cardiovasc Diagn 1996;Suppl 3:55-9.  Back to cited text no. 11
    
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Thomson VS, Varghese L, Joseph G. Type 3 Coronary perforation on optical coherence imaging. J Invasive Cardiol 2019;31:E337-8.  Back to cited text no. 12
    
13.
Gary S. Mintz, MD. Intravascular Imaging of coronary calcification and its clinical implications. JACC 2015;8:4 61-71.  Back to cited text no. 13
    
14.
Pu J, Mintz GS, Biro S, Lee JB, Sum ST, Madden SP, et al. Insights into echo-attenuated plaques, echolucent plaques, and plaques with spotty calcification: Novel findings from comparisons among intravascular ultrasound, near-infrared spectroscopy, and pathological histology in 2,294 human coronary artery segments. J Am Coll Cardiol 2014;63:2220-33.  Back to cited text no. 14
    
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Tuzcu EM, Berkalp B, De Franco AC, Ellis SG, Goormastic M, Whitlow PL, et al. The dilemma of diagnosing coronary calcification: Angiography versus intravascular ultrasound. J Am Coll Cardiol 1996;27:832-8.  Back to cited text no. 15
    
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Bell MR, Garratt KN, Bresnahan JF, Edwards WD, Holmes DR Jr., Relation of deep arterial resection and coronary artery aneurysms after directional coronary atherectomy. J Am Coll Cardiol 1992;20:1474-81.  Back to cited text no. 16
    
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Le MQ, Narins CR. Mycotic pseudoaneurysm of the left circumflex coronary artery: A fatal complication following drug- eluting stent implantation. Catheter Cardiovasc Interv 2007;69:508-512.  Back to cited text no. 17
    
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Aoki J. Coronary artery aneurysms after drug-eluting stent implantation. JACC: Cardiovasc Interven. 2008;1: 2008.  Back to cited text no. 18
    
19.
Vijay SK, Srivastava DK, Tiwari BC, Misra M. Coronary artery aneurysms following drug eluting stents implantation: A retrospective analysis from series of cases at tertiary care cardiac centre over three years. Heart India 2019;7:110-7.  Back to cited text no. 19
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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