Sağ Koroner Arter Kronik Total Oklüzyon Girişiminde Tekrarlayan Koroner Perforasyonun Yağ Embolizasyonu ve Akım Kesme Stratejisi İle Yönetimi
Özet
Kronik total oklüzyon (KTO) lezyonlarının tedavisinde uygulanan perkütan koroner girişimler (PKG), teknik zorlukları ve yüksek komplikasyon riskleri nedeniyle girişimsel kardiyoloji pratiğinin karmaşık işlemlerinden birini oluşturmaktadır. Bu işlemler sırasında karşılaşılan en korkutucu komplikasyonların başında yüksek morbidite ve mortaliteye sebep olabilen, koroner arter perforasyonları (KAP) ve kardiyak tamponad gelmektedir. Bu olgu sunumunda, elli üç yaşındaki kadın hastada sağ koroner arter(RCA), KTO girişimi esnasında bir yıl önce perforasyon gelişen ve otolog yağ dokusu ile başarılı bir şekilde embolize edilen PL dalda, kılavuz tel manipülasyonu sırasında tekrarlayan distal perforasyon gelişimi ve bunun başarılı yönetimi anlatılmaktadır. Tekrarlayan perforasyon sonrasında uygulanan uzamış balon inflasyonu ve otolog yağ embolizasyonuna rağmen kontrast ekstravazasyonunun durdurulamadığı bu olguda, RCA orta segmentinden sağ ventrikül (RV) dalına uzanan uzun bir stent implantasyonu ile rüptür bölgesine giden antegrad akım tamamen kesilerek tam hemostaz sağlanmıştır. Bu olgu, daha önce embolizasyon ile tedavi edilmiş vasküler segmentlerin histopatolojik olarak taşıdığı kırılganlığı ve dirençli distal kanamalarda bir kurtarma stratejisi olarak akım kesme tekniğinin önemini literatür eşliğinde tartışmaktadır.
Percutaneous coronary interventions (PCI) performed for the treatment of chronic total occlusion (CTO) lesions constitute one of the most complex procedures in interventional cardiology practice due to technical challenges and high complication risks. Chief among the most catastrophic complications encountered during these procedures are coronary artery perforations (CAP) and cardiac tamponade, both of which can lead to high morbidity and mortality. This case report describes the successful management of a recurrent distal coronary perforation that occurred during guidewire manipulation in the posterolateral (PL) branch of a 53-year-old woman undergoing right coronary artery (RCA) chronic total occlusion (CTO) PCI, in which the same vascular segment had sustained a perforation one year earlier and had been successfully treated with autologous fat embolization. In the present case, persistent contrast extravasation could not be controlled despite prolonged balloon inflation and autologous fat embolization following the recurrent perforation. Complete hemostasis was achieved by functionally excluding the perforated segment through implantation of a long stent extending from the mid-right coronary artery (RCA) to the right ventricular (RV) branch, thereby abolishing antegrade flow to the rupture site. This case highlights the potential histopathological fragility of previously embolized coronary segments and discusses, in the context of the current literature, the role of antegrade flow interruption as a bailout strategy for refractory distal coronary perforations.
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