Management of Percutaneous Coronary Intervention PCI Complications Dr Hafeesh Fazulu Rahman PIMS Pushpagiri

Dr Hafeesh Fazulu Rahman
MANAGEMENT OF
PCI
COMPLICATIONS
ALGORITHMS FROM THE 2018 AND 2019 SEATTLE
PERCUTANEOUS CORONARY INTERVENTION
COMPLICATIONS CONFERENCE

 Major complications of percutaneous coronary intervention
(PCI) are rare but can be catastrophic if not successfully
managed.
 In contrast to the early days of balloon angioplasty when
complications occurred frequently in the catheterization
laboratory, some complications may be once-a-year or
once-a-career events for many contemporary PCI operators.
 However, with >600 000 PCI procedures performed annually
in the United States, and with escalating patient complexity
and procedural risk, efforts to avoid, recognize, and manage
complications may significantly impact patient survival and
healthcare costs.
Doll JA et al."Management of Percutaneous Coronary Intervention Complications: Algorithms From the 2018 and 2019 Seattle
Percutaneous Coronary Intervention Complications Conference". Circ Cardiovasc Interv. 2020.
Jun;13(6):e008962.doi:10.1161/CIRCINTERVENTIONS
.120.008962. Epub 2020 Jun 12. PMID: 32527193.

 Operators should, therefore, be prepared for complications,
especially if they intend to perform complex and high-risk
procedures.
 Unfortunately, few opportunities exist for training in
complication management.
 Since these events—including
 coronary perforation,
 major dissection,
 hemodynamic collapse,
 no-reflow,
 and entrapped equipment—are rare during routine PCI
procedures, learning by doing is unlikely to be sufficient to develop
competency in complication management.

 Consequently, operators may be slow to recognize evolving
complications, unaware of interventions to evade impending
risk, and uncertain how to swiftly resolve risk when
complications occur.
 In addition, lack of confidence with complication management
promotes risk avoidance, preventing some operators from
attempting complex but indicated PCI procedures, leading to
under treatment of coronary artery disease among patients
with appropriate indication.
 Novel interventional techniques, including hemodynamic
support device-assisted PCI and revascularization of coronary
chronic total occlusions (CTO), have resulted in higher
success rates for complex PCI, but also higher complication
rates.
.120.008962. Epub 2020 Jun 12. PMID: 32527193.

 Therefore, operators who commonly perform CTO interventions
and other complex PCI procedures typically have more frequent
exposure to complications.
 Their experience in assessing and managing complications
may be useful to all PCI operators.
 Therefore, they coordinated the Learning From Complications:
 How to Be a Better Interventionalist course to disseminate
the collective experience of high-volume PCI operators.
 This conference, held in Seattle in August 2018, convened 31
faculty with expertise in CTO and complex interventions from
23 sites.
 There were 142 physician attendees
.120.008962. Epub 2020 Jun 12. PMID: 32527193.

 The curriculum was developed by conference faculty and
included presentations, panels, and moderated
discussions.
 From these sessions, They developed detailed algorithms
to address specific complications and general complication
management.
 These algorithms were then presented to attendees of the
2019 Learning From Complications course for additional
feedback and refinement from faculty and attendees.
 The final algorithms presented here represent the
collective experience of dozens of high-volume PCI
operators.
.120.008962. Epub 2020 Jun 12. PMID: 32527193.

GENERAL PRINCIPLES IN
COMPLICATION
MANAGEMENT
 They recommend a standard set of equipment and
resources to prepare for PCI complications.
 This includes a complications kit or cart that contains
equipment and supplies that may only be required in the
setting of an emergency.
 All catheterization lab physicians and staff should be aware
of the location of the cart and use of the critical equipment it
contains.
 Hospitals without on-site cardiac surgery or advanced
mechanical circulatory support devices should have
clear protocols for patient transfer to a higher level of care
when indicated.
.120.008962. Epub 2020 Jun 12. PMID: 32527193.

COMPLICATION
MANAGEMENT
 They recommend practicing complication management
with regular drills of physicians and staff.
 Cath lab staff should be empowered to voice concerns
about active or potential complications;
 experienced staff may recognize complications
earlier than the physician team and may provide
complementary perspectives on management
.120.008962. Epub 2020 Jun 12. PMID: 32527193.

Recommended Resources for the Management
of PCI Complications
ACLS indicates advanced cardiac life support; ICU, intensive care unit; and PCI, percutaneous coronary intervention.
.120.008962. Epub 2020 Jun 12. PMID: 32527193.

COMPLICATION
MANAGEMENT
 Minor complications—
 non-flow limiting dissections,
 perforations of small septal arteries,
 transient self-limited hemodynamic abnormalities—
may not require specific intervention.
 In fact, in some cases, the aggressive treatment of a
complication may be riskier than careful monitoring and
continuation of the planned PCI procedure.
 Similarly, the decision to complete versus
immediately terminate a planned PCI procedure in the
setting of a complication must be based on the relative
risks of each option to the patient.
.120.008962. Epub 2020 Jun 12. PMID: 32527193.

COMPLICATION
MANAGEMENT
 When a significant complication is
suspected during a procedure, the first
critical decision is whether to act
immediately or pause to evaluate.
 They propose the 60-second rule:
 Is it safe to take 60 seconds to
assess the patient, consider differential
diagnosis, and formulate a plan?
 If not, for example, in the setting of
acute hemodynamic collapse or
ventricular tachycardia, then
management of the presumed issue
must proceed immediately with a goal
to stabilize the patient before further
evaluation and management.
.120.008962. Epub 2020 Jun 12. PMID: 32527193.

COMPLICATION
MANAGEMENT
 If yes, then the following 60 seconds may be used to
 (1) assess the patient;
 (2) communicate the suspected complication to the
staff;
 (3) confirm the diagnosis of the complication or
evaluate for alternatives;
 (4) consider multiple treatment options; and
 (5) call for assistance from colleagues.
 The subsequent action is likely to be more successful
than one performed hurriedly.
.120.008962. Epub 2020 Jun 12. PMID: 32527193.

COMPLICATION
MANAGEMENT
 A critical aspect of complication
management is asking for help.
 It may be useful to double-scrub
operators for high-risk cases, especially
when one operator is acquiring new skills.
 When help is not immediately present,
operators and staff should have access to
contact numbers of other experienced PCI
operators, cardiacsurgeons, and noninvasive
cardiologists.
 A phone call to a colleague who has
previously experienced a similar
complication may provide the knowledge and
confidence needed to salvage the case.
.120.008962. Epub 2020 Jun 12. PMID: 32527193.

DISSECTION
 Coronary artery dissection was a common
complication in the balloon angioplasty era.
 The use of stents has drastically reduced the
incidence of clinically significant dissection, although
major dissections may still result in significant
obstruction of coronary flow, vessel occlusion,
hemodynamic collapse, and even death.
 The ability to promptly identify and manage coronary
artery dissection is a core skill of the interventional
cardiologist.
 Operators who specialize in CTO procedures encounter
dissections more frequently, and at times intentionally
cause dissections to use the subintimal space for
dissection reentry recanalization techniques.
.120.008962. Epub 2020 Jun 12. PMID: 32527193.

Management of coronary
dissections.

DISSECTION
 Novel techniques and devices to manage dissections have
been developed for CTO operators and may also be useful
for treatment of unintentional dissections.
 They recommend against the emergency use of any
technique that operators have not previously mastered during
elective procedures.
 Initial management of dissection should focus on establishing
or maintaining an open artery.
 Balloon dilation of a flow-limiting dissection should be
followed, in most cases, by stent implantation.
 Antegrade injections of contrast are discouraged, as
these may propagate the dissection.
 IVUS may be used to assess the dissection, especially if
the wire position—true lumen versus subintimal—is unclear.

DISSECTION
 For large intramural hematomas, a cutting
balloon may be considered to release the
hematoma before stenting.
 Long dissections may require initial
stenting of the distal margin to prevent
downstream propagation.
 Maintenance of wire position in the true
lumen is critical.
 If position is lost, and the true lumen cannot
be regained by advancing a spring-coil
wire (favored over polymer-jacketed
guidewires), a variety of CTO techniques
may be considered.
 Antegrade dissection-reentry includes
the passage of a wire or CrossBoss
microcatheter in the subintimal space,
followed by reentry to the true lumen with a
wire (with or without the use of a Stingray
catheter).
.120.008962. Epub 2020 Jun 12. PMID: 32527193.

DISSECTION
 Subintimal tracking and reentry is a variant of this
technique in which a knuckled guidewire is advanced until
spontaneous reentry at a distal site, often a bifurcation.
 Retrograde wiring of the vessel can re-establish access to the
true lumen and facilitate antegrade delivery of a stent.
 If these techniques are unsuccessful, or if the necessary
technical expertise is not held by the operator or available
colleagues, referral for emergency coronary artery bypass
graft surgery should be considered.
 In some cases, supporting the patient through an occluded
artery and myocardial infarction may be the best available
option.
.120.008962. Epub 2020 Jun 12. PMID: 32527193.

PERFORATION
 Coronary perforations occur in 0.19% to 1.46% of PCI
Procedures but are as common as 4.8% during CTO
interventions.
 Perforation is associated with a 5-fold increase in in-hospital
mortality risk, as high as 10% to 15% in some series.
 As with dissections, the size and location of the perforation
will determine management strategy, ranging from watchful
waiting to immediate balloon tamponade and permanent
vessel occlusion.
 Although no ideal treatment pathway exists for all
perforations, the following algorithms may be adapted to fit
patient need and operator expertise
.120.008962. Epub 2020 Jun 12. PMID: 32527193.

PERFORATION
 Main vessel perforations may be immediately life
threatening.
 Initial management should include simultaneous efforts to
balloon tamponade the perforation, diagnose, and treat
pericardial tamponade, and summon the support of other PCI
operators and cardiac surgeons as needed
 For severe perforations with active streaming into the
pericardium, immediate placement of a covered stent is the
most effective technique to seal the perforation while
maintaining vessel patency.
 If the available guide is insufficient to maintain balloon
tamponade while simultaneously delivering a covered stent, a
second guide and guidewire can be used for the ping pong
technique
.120.008962. Epub 2020 Jun 12. PMID: 32527193.

PERFORATION
 For less serious perforations, balloon tamponade alone may
be sufficient.
 Standard drug-eluting or bare-metal stents are sometimes
effective for less severe perforations and may be preferable
to covered stents due to higher long-term patency rates.
 However, in other cases, standard stents could worsen a
perforation.
 Emergent referral to cardiac surgery may be required it
percutaneous methods fail.
 Balloon tamponade should also be considered for branch
vessel, distal vessel, or collateral perforations
 Additionally, a perforated side branch may be excluded with a
covered stent in the main branch.
.120.008962. Epub 2020 Jun 12. PMID: 32527193.

PERFORATION
 Bleeding collaterals may require balloon tamponade of both
the antegrade and retrograde blood supply.
 Artery occlusion with coils, thrombin, fat, or
microspheres can be used as salvage strategies.
 As with dissection, loss of guidewire position complicates
management.
 Serial echocardiograms should be performed to assess
for hemopericardium and tamponade.
 Echocardiography contrast delivered via intravenous or
intracoronary route can be used to assess for persistent
bleeding into the pericardial space.
.120.008962. Epub 2020 Jun 12. PMID: 32527193.

PERFORATION
 Even in the absence of active bleeding, echocardiography
may also identify a myocardial hematoma that could result in
hemodynamic compromise (dry tamponade).
 Cardiac tamponade in patients with prior cardiac surgery may
be particularly challenging to manage, since fluid may be
loculated and difficult to drain, but nonetheless cause
hemodynamically significant compression of cardiac
structures.
 Full or partial reversal of heparin anticoagulation should be
considered after all gear has been removed from the
coronary arteries.
 A protamine dose of 25 to 50 mg has been recommended
by some operators to balance risk of bleeding and acute
vessel closure.
.120.008962. Epub 2020 Jun 12. PMID: 32527193.

Management of main vessel
coronary perforations.
.120.008962. Epub 2020 Jun 12. PMID: 32527193.

Management distal vessel or
collateral perforations
.120.008962. Epub 2020 Jun 12. PMID: 32527193.

Distal perfusion with a
microcatheter

Ping pong technique – for
perforation
 “When one balloon is deflated, another balloon
is inflated”

 Perforation occurred
 Inflate a balloon immediately.
 Withdraw 1stGuide wire into aorta, keeping the
balloon there.
 Insert 2nd guide wire (via another access) and
engage in coronary
 Insert 3rd guide wire INTO balloon, deflate balloon,
advance the 2nd wire distally and reinflate balloon
 Insert a covered stent via 3rd guide wire and bring
near the inflated balloon
 Deflate balloon and Inflate stent (after properly
repositioning)
 Remove deflated balloon and its wire

NO REFLOW
 PCI occasionally results in slow or no coronary flow
despite a widely patent epicardial vessel.
 This no-reflow phenomenon may be caused by endothelial
dysfunction, microvascular obstruction, or arteriolar spasm
and is most common in the setting of ST-segment–elevation
myocardial infarction, PCI of degenerated vein grafts, and the
use of atherectomy.
 It is imperative to exclude other causes that may mirror the
angiographic appearance of no-reflow, including dissection,
air embolism, spasm, pseudo-lesion formation, intramural
hematoma, and thrombosis.
 For true no-reflow, various pharmacological treatments have
been recommended

NO REFLOW
 The comparative effectiveness of these agents has not
been tested, although adenosine, nitroprusside, nicardipine,
and verapamil are the most commonly used pharmacological
agents.
 Administration of intracoronary epinephrine has also been
described in cases refractory to conventional
pharmacological measures.
 The algorithm emphasizes the exclusion of flow-limiting
epicardial coronary stenosis followed by distal delivery of
vasoactive treatments though a microcatheter or over-the-
wire balloon
 Glycoprotein IIb/IIIa inhibitors may be considered for some
patients with presumed thrombotic occlusion of the distal
vascular bed, although evidence for this strategy is weak,
.120.008962. Epub 2020 Jun 12. PMID: 32527193.

Management of no-reflow
IABP indicates intra-aortic balloon pump; and IV, intravenous.

UNEXPECTED HEMODYNAMIC
COLLAPSE
 The causes of hemodynamic collapse during PCI are diverse.
 The following algorithm provides our framework to consider
various underlying etiologies of sudden hypotension, after
excluding spurious causes, such as catheter dampening,
acute aortic insufficiency from catheter prolapse, or
equipment malfunction.
 As with other complications, assistance from colleagues may
be required to simultaneously address the
 underlying hemodynamic insult,
 coordinate medical therapy or resuscitative efforts,
 implant and manage a hemodynamic support device,
 and coordinate support staff.
.120.008962. Epub 2020 Jun 12. PMID: 32527193.

UNEXPECTED HEMODYNAMIC
COLLAPSE
 The potential benefits and complications of temporary
mechanical support devices have been reviewed
exhaustively elsewhere.
 Intraaortic balloon pump,
 Impella,
 TandemHeart,
 or ECMO may be considered for persistent
cardiogenic shock,
 with device selection tailored to patient needs
.120.008962. Epub 2020 Jun 12. PMID: 32527193.

Management of unexpected
hemodynamic collapse
AI indicates aortic insufficiency; AV, atrioventricular; BP, blood pressure; CPR,
cardiopulmonary resuscitation; ECLS, extracorporeal life support; and MR, mitral

ENTRAPPED EQUIPMENT
 Entrapped equipment is a rare but particularly challenging
complication that can be encountered during PCI.
 Given the variety of equipment that may be retained in the
coronary artery, and the multitude of mechanisms by which it
may be entrapped, there are no straightforward techniques
applicable to all situations.
 In general, tension applied close to the entrapped wire or
device will be more effective than pulling from outside the
body;
 therefore, advise delivering microcatheters or snares as close
as possible to the point of entrapment before pulling back
everything as a unit.

Stent embolisation
 Stents are MC embolised
 Risk factors – extreme tortuosity, angulationm
and calcification….. By dislodgement from
delivery balloons…
 So commonly lost in RCA and LCx…
 Than in LAD...

Wire fracture
 WIRE
 Seen with CTO pci,
jailed wire technique in
bifurcation
 RISK FACTORS
 Tortuosity
 Calcification
 ISR lesions
 Torqueing wires > 180
degrees

ENTRAPPED EQUIPMENT
 Wires or devices can be trapped into a
guide extension or the guide catheter with
a balloon.
 If a dislodged stent remains on the wire, a
small balloon may be passed through the
stent, inflated, and used to drag the stent
into the guide or guide extender.
 Some operators favor entangling
entrapped stents with 2 or 3 coronary
guide wires.
 Ballooning the area of entrapment, if
delivery of an additional wire and balloon is
possible, may release the entrapped gear.
 Operators should consider abandoning
entrapped equipment if removal is
impossible or may result in migration to a
.120.008962. Epub 2020 Jun 12. PMID: 32527193.

ENTRAPPED EQUIPMENT
 A stent should be used to exclude equipment from the
lumen.
 Short lengths of wire may be stented into the vessel wall with
minimal risk of subsequent complications.
 Stents may be deployed in situ if still on a guide wire or
crushed into the wall with another stent if not.
 These patients may be at increased risk of acute vessel
closure and stent thrombosis, and longer durations of
antiplatelet therapy may be considered.
 Surgery should be considered when equipment cannot be
retrieved or safely abandoned, including any wire or device
that is protruding out of the coronary artery and into the aorta.
 The risk of cardiothoracic surgery must be balanced against
potential thrombotic risk of the retained equipment.

Management of entrapped
equipment.
A, Entrapped guidewire; (B) Entrapped stent; (C) Entrapped atherectomy burr;
and (D) Entrapped other equipment.

 Entangled wire – pass microcatheter…..
Which will separate the wire from the edges of
entagling

AFTER THE COMPLICATION
 Although complications are infrequently the direct result of
physician or staff error, PCI operators may feel guilt and self-
doubt in the aftermath of a major complication.
 Alternatively, they may reflexively blame others or minimize
their own responsibility for the complication.
 These negative impulses may be mitigated by transparent
and nonjudgmental processes to examine and learn from
complications.
 They endorse clinical society recommendations for
constructive peer review of procedural complications,
potentially in the form of morbidity and mortality or case
review conferences.
 The goal of these processes should be quality improvement,
not finding fault.
.120.008962. Epub 2020 Jun 12. PMID: 32527193.

 Ongoing communication with the patient and family is also
critically important.
 Full disclosure of errors and adverse events is recommended by
many hospital systems and has been associated with greater
patient and family satisfaction, and fewer malpractice claims.
 They strongly recommend the PCI operator remain closely
involved in post procedure management.
 Downstream sequelae of PCI complications may include
 acute vessel closure,
 tamponade,
 hemodynamic or electrical instability,
 peripheral vascular injury,
 or stroke.
.120.008962. Epub 2020 Jun 12. PMID: 32527193.

 The PCI operator may be best positioned to anticipate,
recognize, and treat these complications.
 Finally, operators must address their own well-being and that
of their staff.
 Major complications may have profound and lasting impacts
on individuals and sometimes require formal counseling.
 They recommend a team debrief following PCI complications,
whether or not a successful result was ultimately achieved.
.120.008962. Epub 2020 Jun 12. PMID: 32527193.

 This debrief should provide an open forum for
physicians and staff to discuss clinical, interpersonal,
and systems-level issues that contributed to the
outcome.
 This process could result in an after action report, a
concept borrowed from military and disaster response
teams that focuses on identifying opportunities to
improve.
 Efforts to learn from the complication may ultimately
strengthen teams and improve performance for future
procedures.
.120.008962. Epub 2020 Jun 12. PMID: 32527193.

CONCLUSIONS
 PCI is a common invasive procedure with a relatively low
complication rate.
 However, when complications do occur, operators may be
unprepared to manage them.
 Uncertainty about complication management could contribute
to the under treatment of patients with high-complexity,
high risk coronary disease.
.120.008962. Epub 2020 Jun 12. PMID: 32527193.

CONCLUSIONS
 Complication management requires
 preparation,
 early recognition and broad differential diagnosis,
 knowledge of effective techniques,
 team-based communication strategies,
 and multi-disciplinary collaboration.
 an algorithmic approach to complications will improve
procedural outcomes and provide confidence for operators
who plan to perform complex PCI.

Management of Percutaneous Coronary Intervention PCI Complications Dr Hafeesh Fazulu Rahman PIMS Pushpagiri

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