ステント内の再狭窄病変に対するバルーン拡張により冠動脈穿孔を生じ，カバードステントの留置により止血し，救命し得た1例

Repair of Coronary Artery Perforation after Ballooning for In-stent Restenosis by Implantation of a Covered Stent：A case report

患者は狭心症および糖尿病で加療されていた78歳の男性で，2004年2月に左前下行枝の中間部(AHA分類：＃7)の90%狭窄病変に対してステントが留置された．同年9月の冠動脈造影でステント内の再狭窄病変が認められたため，ステント内を高耐圧バルーンで拡張した．直後に冠動脈穿孔が生じた．このためperfusionバルーンカテーテルによる長時間拡張で止血を試みたが，止血できないためカバードステントを留置した．しかし，2時間後より再出血が認められたため冠動脈造影を再施行した．カバードステントの遠位側から造影剤の漏出が認められたため，カバードステントを一部重ねて追加で留置した．24時間後に胸痛および心電図変化が認められた．冠動脈造影ではステント内の中枢部側で完全閉塞が認められたためPCIを施行した．心臓リハビリテーションを行ったが，術後は経過良好で独歩退院した．

78-year-old man with angina pectoris and diabetes mellitus underwent a stent implantation in the mid-segment of the left anterior descending coronary artery, in February 2004. In September 2004, since a coronary angiography revealed a 90% restenosis in the stent, percutaneous coronary intervention was performed. We inserted a non-compliant balloon catheter into the stent and inflated the balloon to 20 atmospheres. After deflation, massive extravascular retention of the contrast media suddenly occurred. Echocardiographical findings also showed cardiac tamponade, leading us to perform continuous cardiac drainage. Since extravascular retention of the contrast media was observed despite long inflation of the perfusion balloon catheter, a covered stent was utilized. After the implantation of the covered stent, extravascular retention of the contrast media disappeared. Several hours later, however, bleeding from the cardiac drainage was observed, and re-bleeding from the coronary artery was suspected. Another coronary angiography was performed, revealing extravascular retention of the contrast media at the distal site of the covered stent, so an additional covered stent was inserted. Although integrity of coronary blood flow was obtained, the patient experienced chest pain and an electrocardiogram showed an ST segment elevation in the V_2-6 leads 24 hours later. Coronary angiography revealed total occlusion at the entry of the proximal covered stent, so percutaneous coronary intervention was re-performed. After careful cardiac rehabilitation, the patient was discharged from hospital without experiencing any other complications.