The C-CAT sign may predict coronary artery perforation in severe calcified lesions during coronary intervention: a case series

Abstract

Background Coronary artery rupture is a rare but fatal complication of percutaneous coronary intervention (PCI). The mortality reaches 19% in patients with the Ellis type Ⅲ classification. The predictors of coronary artery rupture were reported in the previous studies. However, there are few reports showing the risk factors of this threatening complication in terms of intravascular image such as optical coherence tomography and intravascular ultrasound (IVUS). Case Summaries We report the three cases of the coronary artery rupture, who underwent IVUS-guided PCI for severe calcified lesions. All of the three patients developed the Ellis grade Ⅲ rupture, which were successfully managed with perfusion balloon and covered stents. In three cases, the common characteristics were observed at pre-procedural IVUS images. In detail, C-typed CAlcified and residual Thin plaque sign (C-CAT sign) was seen in all of the cases. Discussion These cases provide the insight into the coronary artery rupture in severe calcified lesions. The C-CAT sign at pre-IVUS image may predict the following coronary artery rupture. If we obtain such a unique IVUS image before intervention, we have to consider adapting a smaller balloon size, for example half size down judging from vessel diameter of the reference site or using ablation devices such as orbital atherectomy and rotational atherectomy to prevent coronary artery rupture. Conclusion The C-CAT sign may predict coronary artery perforation in severe calcified lesions during PCI although the larger registries of such intracoronary pre-perforation imaging are warranted in order to correlate different signs with outcomes.

Rotational Atherectomy, Orbital Atherectomy, and Intravascular Lithotripsy Comparison for Calcified Coronary Lesions

“…The risk of those life-threatening conditions can be minimalized thanks to the prevention of the most common causes of dissections, which are balloon over-dilatation or balloon rapture. The same causes can lead to perforation; moreover, the data indicate that intravascular imaging can predict artery perforation [80]. Coronary artery perforation during PCI is most likely while advancing the guidewire.…”

“…If these procedures are not sufficient to close the perforation, subsequent implantation of a covered stent or coil embolization in the distal narrow parts is necessary. The last treatment option is surgical treatment [80]. According to dissections, those which do not limit the flow may not require any specific intervention.…”