Elective percutaneous coronary intervention complicated by coronary rupture

Coronary artery rupture is a rare but potentially fatal complication of percutaneous coronary intervention (PCI) that can result in life-threatening cardiac tamponade. A 69-year-old man was referred for PCI of a 90% calcified lesion in the mid left anterior descending artery (LAD) involving the second diagonal branch (D2; Figure 1, arrow). After the left coronary ostium was cannulated and crossed with two BMW wires, one to the LAD and other to the D2, predilation with a 2.5 mm×15 mm Trek balloon was performed and an unsuccessful attempt was made to cross the stenosis with a 2.75 mm×22 mm Resolute Integrity drug-eluting stent. Predilation was repeated with a 2.75 mm×15 mm Trek non-compliant balloon at high pressure. Suddenly, balloon rupture was detected and the angiogram showed LAD rupture with extensive contrast extravasation into the pericardium (Figure 2, arrows; Video 1). Protamine sulfate was used to reverse the effect of heparin and the drug-eluting stent was deployed with balloon inflation for 10 minutes to seal the type III perforation but, as dye extravasation persisted, a 3.0 mm×19 mm GraftMaster covered stent was superimposed, followed by rapid cessation of contrast leakage (Video 2). The D2 branch was lost (Figure 3, arrows), and periprocedural myocardial infarction occurred. The final image showed pericardial effusion (Figure 4; Video