Septal Collateral Perforation Complicated by Intraventricular Septal Hematoma: A Case Report

A 76-year-old man with effort angina was admitted to Cardiology Department for an elective coronary angiography (CA). Diagnostic CA revealed severely calcified three-vessel coronary artery disease (CAD) with chronic total occlusions (CTO) of the right dominant coronary artery (RCA) and of the left circumflex artery (LCX) ostium, and severe calcific stenosis of the left descending artery (LAD). An urgent percutaneous coronary intervention (PCI) to treat LAD was carried out because of ECG modifications and chest pain immediately after CA. During the procedure a septal collateral perforation occurred leading to abrupt development of a large intraventricular septal hematoma (IVSH). Urgent embolization of the distal septal branch with coils was performed using block and deliver (BAD) technique. Rapid hematoma expansion involved another proximal septal collateral. A prompt second coil embolization was carried out arresting the growth of hematoma expansion. The patient was discharged home in stable condition after close observation in Coronary Care Unit (CCU), and subsequently in a low-intensity care unit. Complete resolution of IVSH was confirmed by transthoracic echocardiogram 2 months later. Timely management of the septal perforation and close echocardiographic monitoring resulted in complete hematoma resolution and a satisfactory outcome.