{'fraction_non_alphanumeric': 0.019651880965749578, 'fraction_numerical': 0.002807411566535654, 'mean_word_length': 5.466424682395644, 'pattern_counts': {'":': 0, '<': 0, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
Seal it to heal it: Potential option for distal wire perforation

Ideally wire perforations of the distal coronary vessels should not occur, but in practice they happen in 0.01–0.31% of procedures [1]. The typical situation includes either the use of a stiff or hydrophiliccoated wire [2] such as the Whisper (Abbott Laboratories, Abbott Park, Illinois) or ChoiCE PT (Boston Scientific, Natick, MA). Likewise, the flexible tip of a coronary wire may have prolapsed and the guidewire is then left leading by its stiffer shaft. If such devices are advanced into the distal vascular bed, the wire may be forced through the wall of a smaller arteriole resulting in extravascular communication and perforation. Although some perforations are quite evident in the catheterization laboratory, others remain initially occult only to become clinically apparent hours after the procedure. If not recognized, bleeding from coronary wire puncture can rapidly lead to death from cardiac tamponade. The diagnosis of coronary perforation should be ruled out in any patient who is hypotensive in the hours after coronary intervention especially if retroperitoneal bleeding is not present. Distal vessel perforation usually responds to conservative measures such as restoration of hemostasis with reversal of anticoagulation and percutaneous drainage of any concurrent pericardial blood. Surgical therapy is usually not needed and may be difficult due to the micropuncture that is transiently bleeding and difficult to localize. Dr. Goel in this issue [3] reports an unusual circumstance encountered with recurrent bleeding and pericardial fluid accumulation after distal coronary puncture with a wire. In this particular case, the wire not only exited the coronary tree, but also found its way into the pulmonary artery suggesting that more than a simple puncture injury may have been involved in the resulting difficulty in hemostasis. The successful solution in this case involved embolizing the local vascular bed with a glue, butyl cyanoacrylate, which is medically used for embolization of AV malformations or varices. There are several reports of successful management of bleeding coronary micropunctures using a variety of embolic approaches including collagen and fibrin injections. Butyl cyanoacrylate, best known as Super Glue (Super Glue) in the nonmedical world, is a highly reactive glue that may be difficult to use successfully if not properly handled. In the presence of hydroxyl ions it undergoes almost instant polymerization. Although relatively nontoxic from a chemical viewpoint, there are reports of inadvertent distant embolization into the brain, heart, and lungs when used for intravascular applications [4]. The best approach to distal vascular wire punctures is prevention first, and, failing that, rapid recognition of tamponade should occur. Spontaneous closure usually occurs with drainage and normalization of coagulation. Further irreversible actions are then not required. Fortunately with distal vascular perforations, the rate of vascular leakage is rarely enough to be life threatening once the potential for tamponade has been relieved. If bleeding persists, definitive therapy can be considered using embolic approaches recognizing that one is now damaging the same myocardium whose preservation of viability was the initial indication for the interventional procedure. How this embolization is accomplished, be it with a mechanical coil, natural clot, or synthetic glue, requires local expertise and measured consideration of risk/benefit.