Flow Halted to Save Life: Functional Annulment of the Distal Right Coronary Artery Using a Covered Stent for Refractory Perforation During Chronic Total Occlusion Intervention

Percutaneous coronary intervention (PCI) is a minimally invasive treatment that reestablishes the flow in occluded coronary arteries with the use of wires, balloons, and stents. Chronic total occlusion (CTO) PCIs are one of the most challenging procedures in interventional cardiology because the morphology of the lesions is complex, the duration is prolonged, and there is a higher risk of complications like vessel perforation. The management of distal perforations can sometimes be very problematic when conventional approaches have failed. A 47-year-old male was admitted with acute chest pain and diagnosed with an inferior wall myocardial infarction. Coronary angiography revealed a CTO of the right coronary artery (RCA). Standard CTO techniques, including guidewire escalation, microcatheter support, sequential balloon angioplasty, and deployment of a drug-eluting stent (DES), were initiated to perform PCI. During the procedure, distal RCA perforation occurred. Initial management with prolonged balloon tamponade was unsuccessful, and a covered stent could not be advanced due to the tortuosity of the vessel. To address this, an alternative approach was employed whereby access was obtained via the marginal branch by dilating the stent struts of the previously deployed DES, allowing the covered stent to be advanced and deployed into the acute marginal branch, effectively isolating the perforated segment. This case illustrates a novel bailout approach for managing distal RCA perforation during complex CTO-PCI. When the delivery of a covered stent is not possible via a standard approach, accessing the main vessel through a side branch and stent strut dilatation may offer a viable route to successful sealing of perforation. To the best of our knowledge, this is the first case in the literature of distal RCA perforation that was successfully managed by functional annulment using a covered stent delivered through a side branch after stent strut dilatation. This technique illustrates a creative and effective solution for a rare but potentially catastrophic complication. The patient remained hemodynamically stable post-procedure. Serial echocardiography demonstrated no pericardial effusion, and cardiac biomarkers appropriately trended down. The patient was asymptomatic at the three-month follow-up with preserved left ventricular function.