How should I treat guidewire-induced distal coronary perforation?

*Corresponding author: Department of Cardiology, All India Institute of Medical Sciences, New Delhi 110 029, India. E-mail: ramakgmc@rediffmail.com PRESENTATION OF THE CASE A 45-year-old hypertensive male had presented with recent onset NYHA class II angina and dyspnoea on exertion of six-weeks duration. The exercise treadmill test was strongly positive with significant ischaemic changes occurring in stage 1 of Bruce protocol. Angiogram showed a total occlusion of left circumflex artery and obtuse marginal branch (OMB) (Figure 1). The patient underwent PCI after an informed consent. The patient was given 600 mg clopidogrel one day prior and 5,000 U intravenous heparin was given at the start of the procedure. A Judkins left (JL) 3.5 guiding catheter (Cordis Corp., Johnson & Johnson, Miami Lakes, FL, USA) was used to hook the left main artery. As a soft coronary wire could not be negotiated through the lesion, a hydrophilic Crosswire® NT (Terumo Medical Corporation, Somerset, NJ, USA) was used to cross the lesion. The distal end of the guidewire was parked in a moderate sized OM branch. The lesion was stented with Bx SonicTM (Cordis Corporation, Johnson & Johnson, Miami Lakes, FL, USA) 2.75×28 following predilatation. The stent was postdilated with a PowerlineTM 3×10 balloon (Biosensors Interventional Technologies Pte Ltd, Singapore). The end result appeared satisfactory (Figure 2). Intravenous tirofiban (0.4 μg/kg/min over 30 min followed by 0.1 μg/kg/min continuous infusion) was given. The patient had hypotension two hours later, which was not associated with chest pain or any electrocardiogram (ECG) change. Echocardiography showed significant pericardial effusion CASE SUMMARY