Use of a double-covered stent-in-stent technique to manage persistent coronary perforation

A sixty-four year old man with a previous history of CABG was referred for coronary angiography that revealed a critical stenosis of the right posterior descending artery at the anastomosis point of the saphenous vein graft (Figure A). Percutaneous intervention was initiated by engagement of the saphenous graft ostium with a 6F JR guiding catheter, followed by crossing the lesion with a hydrophilic guidewire. A drug-eluting stent, 2.25 x 23 mm in size, (Xience, Abbott Vascular, USA) was implanted at 14 atm pressure. Control angiography revealed a marked Ellis type IV coronary perforation with leakage of blood into the pericardial cavity (Figure B). Subsequently, the patient deteriorated hemodynamically with severe chest pain and hypotension. Echocardiography showed a marked pericardial effusion along with right ventricular collapse. Protamine sulfate was used to reverse anticoagulation followed by administration of IV fl uids and emergency pericardiocentesis. A 2.5 x 15 mm balloon (Sprinter Legend, Medtronic, USA) was advanced for 10 minutes of prolonged infl ation, which failed to heal the perforation (Figure C). A 2.80 x 19 mm covered stent (Graftmaster, Abbott Vascular, USA) was implanted at the level of the perforation.