16. AngioClub: A Nightmare in the Left Main: Atherectomy, Perforation, and Bailout

!https://cathmasters.com/wp-content/uploads/2026/10/16.-AngioClub-A-Nightmare-in-the-Left-Main-Atherectomy-Perforation-and-Bailout.webp CathMasters (Drs. **Amit Goyal**, **Daniel Ambinder**, and **Nazli Okumus**), with guests Drs. **Mina Fares**, **Fariyal Cheema**, and **Jeremy Langrish** discuss the management of an unprotected distal left main (LM) percutaneous coronary intervention (PCI) complicated by an Ellis grade III coronary perforation. An 88-year-old man presented with a non–ST-elevation myocardial infarction (NSTEMI), heavily calcified critical distal LM disease (culprit), and a chronic total occlusion (CTO) of the right coronary artery (RCA). The team walks through heart-team decision-making for palliative-intent LM PCI, the choice to forgo upfront mechanical circulatory support (MCS), rotational atherectomy and intravascular ultrasound (IVUS)–guided calcium modification, a provisional LM-to-left anterior descending (LAD) stent strategy, and the real-time, stepwise rescue of a large perforation — balloon tamponade, pericardiocentesis with autotransfusion, and a covered stent landed at the LAD ostium to spare the circumflex. CathMasters is for educational purposes only. CathMasters is for educational purposes only. Music by Elijah K from Pixabay ### Media # Pearls 1. **“ST elevation in aVR” is a barometer of global distress, not a culprit locator.** aVR ST elevation with diffuse ST depression signals left main/three-vessel disease or circumferential subendocardial supply–demand mismatch; only roughly 10–25% of such patients have an acute thrombotic occlusion. In this case, the changes resolved once pain/hemodynamics normalized. 2. **After CHIP-BCIS3, mechanical support is a selective — not reflexive — decision.** In complex high-risk PCI with ejection fraction ≤35%, routine elective left-ventricular unloading with a microaxial flow pump did not improve the composite outcome and showed a signal toward higher cardiovascular death. A hemodynamically stable patient with preserved EF, as here, generally does not warrant upfront support — and a 14-French femoral sheath carries real risk in a frail 88-year-old. 3. **“The last 5% can guarantee you a 100% complication.”** For a disease-free, favorably angulated circumflex ostium (Medina 1,1,0), the stepwise provisional single-stent LM-to-LAD strategy is the default and reduces target-lesion revascularization compared with upfront two-stent approaches. Define the procedural goal first — here, symptom relief, not survival — which justified leaving the RCA CTO untouched. 4. **Ellis III perforation: tamponade buys time, the covered stent provides the definitive seal — and post-dilation is mandatory.** Immediate balloon inflation at/across the perforation stabilizes the patient while the team mobilizes; a polytetrafluoroethylene/polyurethane covered stent seals large-vessel perforation, but residual “endoleak” around the stent is common and must be addressed with high-pressure post-dilation before reaching for a second stent. 5. **In a left main bifurcation perforation, land the covered stent at the LAD ostium to spare the circumflex — and manage the bleed in parallel.** Deliberately avoiding the distal LM/circumflex preserves flow and allows full wall apposition; keep an LM-sized covered stent on standby as bailout. Pericardiocentesis with autotransfusion (cell saver) is salvage therapy for hemorrhagic tamponade — heparinize each collection bag (10,000 units) so the perfusionist can re-infuse the patient’s own blood. # Notes **1. How should the high-risk ECG pattern of aVR ST elevation with diffuse ST depression be interpreted?** - The pattern reflects a net ST vector toward aVR from widespread subendocardial injury; it is associated with left main or three-vessel disease and increased mortality, but has only ~10–14% positive predictive value for acute occlusive myocardial infarction. - Broad differential includes nonocclusive coronary disease and demand/supply mismatch (hypotension, sepsis, severe anemia, aortic stenosis) and repolarization abnormalities; resolution with pain relief or hemodynamic correction argues against acute occlusion. - In this NSTEMI presentation, the pattern correctly flagged critical distal LM disease as the culprit, confirmed angiographically. **2. How does the heart team frame revascularization in a frail elderly patient with complex disease?** - The intent was explicitly palliative — symptom relief rather than prognostic gain — which removed the RCA CTO from consideration and focused treatment on the LM. - The patient was deemed a non-surgical candidate; after continued angina despite optimal medical therapy, the multidisciplinary team, patient, and family accepted PCI with a frankly stated 5–10% risk of a serious periprocedural complication. - Procedural planning emphasized “planning for success”: daytime timing, a full team brief, and preparation for complex PCI with calcium-modification algorithms available. - Shared-decision making with the patient and their family guided by their own goals is paramount in these complex cases. **3. When is mechanical circulatory support indicated for high-risk PCI?** - CHIP-BCIS3 randomized 300 patients with complex disease and EF ≤35% to elective microaxial flow pump (Impella CP) versus standard care; routine unloading did not improve the hierarchical composite outcome and trended toward higher cardiovascular death. - A CHIP-BCIS3 hemodynamic substudy showed the pump reduced inotrope use but increased loss of pulse pressure and did not prevent myocardial stunning. - Randomized evidence does not support routine MCS outside cardiogenic shock; selection should weigh EF, baseline blood pressure, lesion predictability, and access risk. This patient — stable, normal biventricular function — had PCI without upfront support, with femoral access and bailout strategies kept in mind. - Enjoy CathMastes Ep 4 (Data to Delivery: CHIP-BCIS3 — Microaxial Flow Pump Support for High-Risk Complex PCI with Dr. Saraschandra Vallabhajosyula) to learn more about CHIP-BCIS3. **4. How is heavily calcified left main disease modified and assessed?** - Left main atherectomy can be performed from the radial or femoral artery. Adequate support and appropriate guide selection are key. In this case, the setup was: right radial, 7.5-French sheathless guide for maximal support; workhorse wire and microcatheter exchanged for a dedicated 0.009-inch rotational wire; upfront rotational atherectomy chosen because the stenosis was too tight to safely balloon or image first. - Burr selection: aim for a burr-to-artery ratio of ~0.5–0.6; a relatively larger burr (here 1.75 mm) can be chosen when debulking nodular calcium rather than simply creating a channel. Note: the recording’s “no more than two-thirds” rule of thumb is more liberal than the published 0.5–0.6 ratio. - Technique: rotational speed ~160,000 rpm (within the safe 135,000–180,000 rpm range), short runs of 10–15 seconds (≤30 s) with a pecking motion and rest between runs, avoiding decelerations >5,000 rpm. - No-reflow prevention: continuous flush of heparinized saline with verapamil and nitroglycerin in the bag or vasodilators through the manifold between runs; left-sided atherectomy rarely needs temporary pacing, so pacing wires were abandoned for LM cases (a small atropine dose is used for large dominant RCA atherectomy instead). Aminophylline pre-treatment can also mitigate atherectomy-related bradyarrhythmias. - IVUS findings guided the plan: distal LM was the tightest concentric calcium with fractures at 2, 7, and 11 o’clock; ostial LAD showed nodular calcium (a difficult subset with no single effective device); landing zones measured ~4.0 mm (proximal LAD) and ~5.0 mm (LM body). A 1:1 (4.0 mm) non-compliant balloon confirmed good expansion before stenting. **5. Why a provisional single-stent strategy for the distal left main bifurcation?** - In this case, the circumflex ostium was widely patent with a favorable (~90°) take-off (Medina 1,1,0), so side-branch compromise risk was low; it was protected with a jailed wire. - EBC MAIN established the stepwise provisional approach as the default for true LM bifurcation disease, with lower target-lesion revascularization and comparable death/MI versus upfront two-stent strategies, especially for smaller/shorter side branches. - Stent selected by IVUS: 4.0 × 28 mm drug-eluting stent capable of expansion to 5.0 mm in the LM body. **6. How is an Ellis grade III perforation recognized and managed step by step?** - Recognition: during non-compliant balloon inflation, the patient developed chest pain, hypotension (110/70 to 80/50 mmHg), and tachycardia; angiography showed frank contrast extravasation (Ellis III) with an uncertain LM-versus-LAD source. Sharp pain during balloon/stent work should always raise suspicion. - First step — balloon tamponade: the 4.0 mm balloon already in the guide was readvanced into the LM and inflated to stop bleeding and buy thinking time; note this occludes the only remaining vessel (RCA CTO), so inflations had to be intermittent to allow perfusion. - Reduce cognitive load and mobilize the team in parallel: alert the cath-lab staff, call a colleague from the adjacent lab, and involve intensive care for airway/hemodynamic support while the operator focuses on source control. - A drug-eluting stent (4.0 × 28 mm) was deployed LAD-to-LM in the hope a flap would seal the channel; but bleeding continued. - Hemorrhagic tamponade management: pericardial drain with autotransfusion via cell saver (~1,500 mL aspirated over the case), large-bore femoral venous access for volume/blood, and successful resuscitation from a brief pulseless electrical activity arrest. Heparinize each autotransfusion collection bag (10,000 units). - Definitive seal: a PK Papyrus covered stent (3.5 mm) was landed precisely at the LAD ostium — deliberately sparing the distal LM and circumflex to preserve flow and achieve wall apposition. Residual leak was addressed with high-pressure post-dilation using a 4.0 mm non-compliant balloon; repeat angiography confirmed no further leak and drain output fell. Covered stents are the primary emergency treatment for large-vessel perforation. - Bailout thinking: an LM-sized covered stent was on standby in case of upstream leak, accepting circumflex occlusion; limited covered-stent expandability and vessel-size mismatch make LM covered-stenting challenging. - Anticoagulation: a reasonable activated clotting time was maintained while equipment remained in the coronaries (two stent layers, ongoing manipulation); reversal is considered only after equipment is removed with ongoing leak and no planned further intervention. Here heparin was not reversed because source control was achieved — reversal/protamine is used more commonly after wire-perforation coiling, where thrombus (not the coil) seals the hole. - Finish: final IVUS confirmed well-apposed, well-expanded stents from LAD to LM. The patient recovered over the following days with a good angiographic result and no need for staged re-intervention. ### **References** 01. **Ezad SM, Ryan M, Khan SQ, et al. Impact of left ventricular unloading on hemodynamics and stunning in complex PCI: a CHIP-BCIS3 substudy.** ***J Am Coll Cardiol.*** **2026;88(13):1454-1466.** PMID: 42554527**.** 02. **Arunothayaraj S, Egred M, Banning AP, et al. Stepwise provisional versus systematic dual-stent strategies for treatment of true left main coronary bifurcation lesions (EBC MAIN, 3-year).** ***Circulation.*** **2025.** PMID: 39907022**.** 03. Hildick-Smith D, Egred M, Banning A, et al. The European Bifurcation Club left main coronary stent study: a randomized comparison of stepwise provisional vs. systematic dual stenting strategies (EBC MAIN). *Eur Heart J.* 2021;42(37):3829-3839. PMID: 34002215. 04. **Cerrato E, Pavani M, Barbero U, et al. Incidence, management, immediate and long-term outcome of guidewire and device related grade III coronary perforations (G3CAP — Cardiogroup VI Registry).** ***Am J Cardiol.*** **2021;143:37-45.** PMID: 33387472**.** 05. Wańha W, Januszek R, Kołodziejczak M, et al. Procedural and 1-year outcomes following large vessel coronary artery perforation treated by covered stents implantation: multicentre CRACK registry. *PLoS One.* 2020;15(12):e0244270. PMID: 33979357. 06. **Riley RF, Patel MP, Abbott JD, et al. SCAI expert consensus statement on the management of calcified coronary lesions.** ***J Soc Cardiovasc Angiogr Interv.*** **2024;3(2):101259.** doi:10.1016/j.jscai.2023.101259**.** 07. Fan LM, Tong D, Mintz GS, Mamas MA, Javed A. Breaking the deadlock of calcified coronary artery lesions: a contemporary review. *Catheter Cardiovasc Interv.* 2021;97(1):108-120. doi:10.1002/ccd.29221. 08. De Maria GL, Scarsini R, Banning AP. Management of calcific coronary artery lesions: is it time to change our interventional therapeutic approach? *JACC Cardiovasc Interv.* 2019;12(15):1465-1478. doi:10.1016/j.jcin.2019.03.038. 09. Giannini F, Candilio L, Mitomo S, et al. A practical approach to the management of complications during percutaneous coronary intervention. *JACC Cardiovasc Interv.* 2018;11(18):1797-1810. doi:10.1016/j.jcin.2018.05.052. 10. Kandzari DE, Birkemeyer R. PK Papyrus covered stent: device description and early experience for the treatment of coronary artery perforations. *Catheter Cardiovasc Interv.* 2019;94(4):564-568. doi:10.1002/ccd.28306. 11. Davidson LJ, Cleveland JC, Welt FG, et al. A practical approach to left main coronary artery disease: JACC state-of-the-art review. *J Am Coll Cardiol.* 2022;80(22):2119-2134. doi:10.1016/j.jacc.2022.09.034. 12. Brouner M, Hammock J, Doppalapudi H. Does ST elevation in lead aVR require an emergent trip to the catheterization laboratory? *JAMA Intern Med.* 2023;183(3):263-264. doi:10.1001/jamainternmed.2022.5663. 13. Larsen TR, Huizar JF. Direct autologous blood transfusion in cardiac tamponade: where safety is not always first. *J Cardiovasc Electrophysiol.* 2019;30(8):1313-1315. doi:10.1111/jce.14006. 14. Lawton JS, Tamis-Holland JE, Bangalore S, et al. 2021 ACC/AHA/SCAI guideline for coronary artery revascularization. *Circulation.* 2022;145(3):e18-e114. doi:10.1161/CIR.0000000000001038.