S114 J O U R N A L O F T H E A M E R I C A N C O L L E G E O F C A R D I O L O G Y , V O L . 6 9 , N O . 1 6 , S U P P L S , 2 0 1 7

[INTERVENTIONAL MANAGEMENT]Procedural step. IVUS revealed the dissection of LAD, which extendedinto the left main trunk. With a narrower true lumen compressed byan extensive false lumen filled with a hematoma. Similar findingswere confirmed in the LCx.Initially, we performed a cutting balloon angioplasty of the LAD to

create communications between the true and false lumens, aiming thereduction of the compression, and restore the distal coronary flow. A3.0 mm cutting balloon was inflated to12 atm in the distal segment ofthe LAD. After ballooning, coronary flow remained TIMI II flow. Sub-sequently, we treated the left circumflex artery (LCx) with a 3.5 mmcutting balloon dilated to 12 atm. After ballooning, LCx flow wasimmediately restored to TIMI III flow.Assuming that the 3.0mm balloon was not enough size to recanalize

the LAD, we used 3.5 mm and 4.0 mm cutting balloon in the mid LADrespectively. As the result, the LAD flow further worsened to TIMI I.Since IVUS revealed the extension of the hematoma into the LMT, weconsidered that additional ballooning would not be effective anddecided to implant a drug-eluting stent (DES) into an LAD-LMTsegment. After the stenting, LAD flow was restored to TIMI III.

Case Summary. In the treatment of spontaneous coronary arterydissection, revascularization with a combination of the cuttingballoon and the stent is effective. IVUS findings are crucial to deter-mining the choice of appropriate device and techniques to restore thecoronary flow.

TCTAP C-025

Management of Coronary Perforation and Subsequent CoveredStent Dislodgement

Ya-Ling Yang11Taipei Veterans General Hospital, Taiwan

[CLINICAL INFORMATION]Patient initials or identifier number. Shieh-101162392Relevant clinical history and physical exam. The 82-year-old man hadtype 2 diabetes mellitus and hypertension. He was admitted for pe-ripheral arterial occlusive disease with the presentation of drygangrene at right 1st toes and left 5th toe. However, non-ST-segmentelevation myocardial infarction combined with acute respiratoryfailure was developed during the hospital course.Relevant test results prior to catheterization.CK peak: 668 U/LTroponin I peak: 31.47 ng/mlBedside heart echo: LVEF: 40% with global hypokinesia

Relevant catheterization findings. LMand triple vessel disease (LM: -ostium:50% stenosis, LAD: -P:80% stenosis,

- M: Segmental stenosis up to 60% stenosis,- D: Up to 90% stenosis, LCX: nondominat,- P to -M: 50% stenosis, -OM1:up to 50% stenosis,- OM2: 60% stenosis, -D:90% stenosis,

RCA: Dominant, -M 70% stenosis,

- D: Segmental stenosis up to 40% stenosis,- PL: Diffuse lesion up to 90% stenosis, -PDA: luminal irregularity

[INTERVENTIONAL MANAGEMENT]Procedural step. A guide (XB 3.5 7F) and a floppy wire were used. LADlesions were pre-dilated with a 3.0/15 mm Ryujin balloon catheter andsubsequently stented with a 3.0/30 mm BMS (at middle LAD) and a3.5/15 mm BMS (at proximal LAD). However, Ellis type II coronaryperforation at middle LAD occurred after post-dilation. Prolongedballoon inflation with a 3.0/15 mm Ryujin balloon catheter was tried toseal the perforation. However, the bleeding was unable to stop byprolonged balloon inflation. We then removed the balloon catheterand soon delivered a 3.0/16 mm covered stent to the perforation sitebut failed. Unfortunately, the covered stent dislodgement occurred

J O U R N A L O F T H E A M E R I C A N C O L L E G E O F C A R D I O L O G Y , V O L . 6 9 , N O . 1 6 , S U P P L S , 2 0 1 7 S115

while we withdrew the covered stent. Immediate pericardiocentesiswas performed. The whole system was then removed and an 8FrJudkins left guiding catheter was used to engage left main coronaryartery. A choice PT guidewire and a 3.0 mm balloon catheter wereused for prolonged balloon inflation again and simultaneously a 0.014whisper wire was managed to get through the dislodged covered stentsuccessfully. A Goose Neck snare was used for covered stent retrievalbut it failed. We then used small balloon technique with a 1.25/10 mmRyujin balloon catheter advanced through the dislodged coveredstent. After inflating the balloon distal to the stent, we withdrew theballoon together with the covered stent. Fortunately, followed angi-ography showed coronary perforation was sealed after prolongedballoon inflation.

Case Summary. Prolonged balloon inflation with pericardiocentesis isthe mainstay of therapy for coronary perforation. Covered stents alsocan effectively seal coronary perforation. However, covered stentdislodgement can occur because they are bulky with limited flexibilityand thus may not be easy to deliver in difficult anatomy. Fortunately,the large profile design of the covered stent also makes it possible toget through an undeployed covered stent by a coronary wire. In ourcase, an 8 French large guiding catheter allowed us simultaneously tomanage the coronary perforation by prolonged balloon inflation andcovered stent dislodgement by either snare technique successfully.

TCTAP C-026

ST-segment Elevation Myocardial Infarction with AmbiguousAngiographic Findings When Coronary Computed TomographyProvides New Insights

Giuliana Capretti,1 Luca Ferri,1 Massimo Slavich,1 Manuela Giglio,1

Luciano Candilio,2 Alberto Margonato,1 Antonio Colombo,3

Alaide Chieffo1

1San Raffaele Hospital, Italy; 2Imperial College London, San RaffaeleHospital, Italy; 3EMO GVM Centro Cuore Columbus, San RaffaeleHospital, Italy

[CLINICAL INFORMATION]Patient initials or identifier number. CIGRelevant clinical history and physical exam. A 49-year-old woman with nosignificant cardiovascular risk factors was admitted to the emergencydepartment with typical angina and sweating prior to a yoga class andfollowing a particularly stressful period involving divorce andredundancy.Relevant test results prior to catheterization. ECG showed anterolateralST-segment elevation, bedside echocardiogram revealed mild leftventricular systolic dysfunction with apical akinesia. Serum troponin-T concentration was elevated. The patient was loaded on aspirin andclopidogrel and taken for emergency cardiac catheterization.Relevant catheterization findings. Coronary angiogram via right radialaccess (6F) showed non-obstructive disease in right coronary andcircumflex arteries and segmental luminal narrowing in small distalleft arterial descending (LAD) artery. This was not thought to be due tosignificant stenosis [Thrombolysis In Myocardial Infarction (TIMI)-3].There was no clear angiographic evidence of coronary dissection orspasm. Left ventriculogram confirmed apical akinesia.