ACI 2018 - Best of the Young - When Nothing Fits - Saud Khawaja

1. When nothing
fits…
Dr Saud Khawaja – Cardiology SpR
Dr Paul Williams – Consultant Cardiologist

2. BC, 72 year old male
 PMHx:
 Permanent AF
 CABG 1983: SVG to LAD, OM and PDA with jump grafts to diagonal
(LAD) , IM (OM) and PLV + lateral OM (PDA) (LIMA not used)
 Angina since 1987 – medically managed
 Ant STEMI 2012 – Culprit occlusion of SVG to LAD – medically
managed. Natives occluded. Patent SVG to RCA (sole remaining
vessel collateralising LAD and Cx)
 Offered redo-CABG but patient refused
 Admitted with NSTEMI
 3/12 hx of worsening angina
 Ongoing rest pain with dynamic ST depression

3. Angiogram
Native
left
Native
right
SVG to RCA collateralizing to LAD/LCX
Critical SVG
lesion

4. PCI to SVG
 Following angiogram patient became unstable with gross
ischaemic changes despite intracoronary GTN
 Decision on intervention as last remaining vessel and unstable
 Upsized to 7Fr sheath and 7Fr AL 0.75 GC (Medtronic)
 Spider 6.0 distal protection device deployed
 Direct stenting with 5.0 x 30 mm Resolute Onyx (Medtronic)
However

5. Perforation
 Perforation of SVG to RCA after stent insertion
 Echo - no effusion (presumed bleeding into mediastinum)
 Spider retrieved
 Attempted balloon tamponade
 Immediate haemodynamic collapse (sole remaining vessel)
 Largest covered stent on shelf 4mm diameter
 Felt would not seal perforation given limited stent expansion
 If failed to seal then no other percutaneous options available
 Urgent surgical consult
 Not for surgery given instability and re-do operation
 Protamine given
 Ongoing frank extravasation
 Options?

6. Covered stent
 5.0 x 22mm Advanta V12 (Maquet) iliac stent obtained from
vascular radiology
 120 cm length over the wire
 0.035” wire compatible
 PIS states 6Fr compatible
 Issues:
 Needed exchange length 0.035” wire
 Attempted to wire with standard 0.035” J-tipped wire – would not
pass through stent.
 Wired with 0.035” Terumo Glidewire
 Guide catheter too long (110cm) for 120cm shaft device
 Cut proximal hub of guide catheter to shorten
 Lost haemodynamic monitoring and ability inject contrast

7. Nearly Home …
 Covered stent won’t pass through 7Fr guide catheter
 Why?
 Vascular radiology compatibility is for guiding sheaths, coronary
compatibility is for guide catheters
 We were using 7Fr AL 0.75 (Medtronic) coronary guide catheter
with an internal diameter of 2.06mm
 However a vascular 6F guiding sheath has an internal diameter of
2.21mm
 Hence a “6Fr-compatible” vascular stent may not fit in a 7 Fr
coronary guide catheter
ID 2.21mm
ID 2.06 mm
6 Fr Destination
(Medtronic) Sheath
7 Fr AL 0.75 ( Medtronic)
Guide catheter
6 Fr Destination (Medtronic) Sheath

8.  Upsized to 8Fr sheath and 8Fr AL 0.75 guide catheter
 Angiogram – still frank extravasation
 Guide again shortened by cutting of hub
 Terumo wire passed into SVG
 Unfortunately insufficient wire support to deliver covered stent
 5 Fr JR4 diagnostic catheter used to exchange Terumo for standard
0.035” guidewire (mother and child technique)
 Allowed stent to pass
8Fr AL 0.75 GC
5Fr JR4
Diagnostic
catheter

9. Covered Stent deployed
• Used previous stent to guide covered stent position (no injection
possible)
• Still no haemodynamic monitoring or contrast injections available

10. Hub re-connection
• 6 Fr guide catheter hub inserted into end of 8 Fr guide to allow
pressure monitoring and contrast injection
ID
2.29 OD 2.08
6Fr AL0.75 GC
hub end
8Fr AL0.75 GC
proximal end
• No ongoing leak from
perforation
• Stent under expanded
• SVG rewired with Sion Blue
and post dilated with 5 x
15mm NC Sprinter
6Fr GC hub
6Fr GC end inserted into
cut 8Fr end
8Fr AL0.75
GC
shortened

11. Progress
 Returned to CCU – haemodynamically stable
 Echo – no effusion
 CT chest – Mediastinal haematoma.
 Good quality LIMA.
 Calcified SVG – risk factor for perforation
 No further ischaemia – discharged day 3
 Discussed in MDT – for redo CABG given long term patency of
SVG with overlapping DES and covered stent uncertain
 Elective CABG with LIMA – LAD performed
 Doing well at follow-up
 Angina free for first time since 1987
Stent
SVG
calcification

12. Summary
 Vascular radiology equipment can be used in coronaries but
requires extensive modification to standard kit
 There are crucial differences in how equipment compatibility
is graded (guide vs guiding sheath size)
 Stock a full range of covered stents (we now have a 5mm
stent on the shelf)
 Thank You