Letter to the Editor Percutaneous safenectomy: A potentially dreadful complication of cutting balloon angioplasty in safenous vein grafts Worawut Tassanawiwat b , Giuseppe G.L. Biondi-Zoccai b , Giuseppe Sangiorgi a , Ioannis Iakovou a,b , Eleutheria Tsagalou b , Gloria Melzi b , Lei Ge a , Nuccia Morici b , Nicola Corvaja a , Antonio Colombo a,b, T a EMO Centro Cuore Columbus, Milan, Italy b Interventional Cardiology Unit, St. Raffaele Hospital, Milan, Italy Received 16 December 2004; accepted 1 January 2005 Available online 22 March 2005 Abstract Vessel perforation is an uncommon but potentially life-threatening complication of percutaneous coronary intervention and is often associated with the use of atheroablative devices. While effective management means are currently available, such as PTFE-covered stent, pericardiocentesis, and perfusion balloon, a timely and skillful approach is of paramount importance to solve this dreadful complication. We hereby describe a case of saphenous vein graft (SVG) perforation occurring after cutting balloon angioplasty for in-stent restenosis. Despite the immediate occurrence of cardiac arrest due to massive extravasation of contrast in the mediastinum with pericardial tamponade, deep catheter intubation enabled the deployment of two PTFE-covered stents and subsequent sealing of the leak with repeated inflation of a perfusion balloon, while hemopericardium was drained by pericardiocentesis. This clinical vignette emphasizes the role of optimal backup in order to deploy life-saving devices and successfully manage life-threatening pericardial tamponade due to SVG rupture. D 2005 Elsevier Ireland Ltd. All rights reserved. Keywords: Cardiac tamponade; Vessel perforation; Cutting balloon; Stent 1. Introduction Iatrogenic coronary or aorto–coronary bypass graft rupture is an uncommon but life-threatening complication of percutaneous coronary intervention (PCI), but its occurrence in degenerated or diffusely diseased saphenous vein grafts (SVG) treated with atheroablative/debulking devices is incompletely established. We hereby report an interesting case of SVG perforation occurring after cutting balloon angioplasty (CBA) for in-stent restenosis, which emphasizes the risk of CBA in SVG, and the importance of a timely and thorough approach to solve this dreadful complication. 2. Case A 57-year-old man with previous CABG with SVG implantation to the obtuse marginal (OM), underwent PCI with stenting on the SVG to OM. Because of recurrent angina, he repeated angiography which disclosed distal stent in-stent restenosis (Fig. 1). After deployment of a JR4 6 Fr catheter and a distal filter device, predilation of the SVG lesion was attempted with a 2.5 Â 20 mm semi-compliant balloon at up to 16 atm without success. CBA (Boston Scientific) was thus performed with a 3.0 Â 10 mm device dilated at 14 atm. Repeat angiography immediately follow- ing cutting balloon deflation demonstrated free flowing contrast extravasation into pericardium and mediastinum due to type 3 vessel perforation, associated with sudden cardiac arrest, and as soon as cardiopulmonary resuscitation (CPR) was started, deep catheter intubation was performed 0167-5273/$ - see front matter D 2005 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2005.01.017 T Corresponding author. EMO Centro Cuore Columbus, via Buonarroti 48, 20145 Milan, Italy. Tel.: +39 24812920; fax: +39 248193433. E-mail address: info@emocolumbus.it (A. Colombo). International Journal of Cardiology 106 (2006) 418 – 419 www.elsevier.com/locate/ijcard