Treatment of Coronary Perforations

www.bellvitgehospital.cat
Treatment of coronary perforations:
material and techniques
Session 6: Safety Aspects
Dr. Luis Teruel
Àrea de Malalties del Cor
Hospital Universitari de Bellvitge - IDIBELL
Universitat de Barcelona
L’Hospitalet. Barcelona. Spain

Bellvitge University Hospital
L’Hospitalet de Llobregat. Barcelona. Spain.
Three cath labs.
Reference for 1.25 million people.
1600 PCIs/year.
200 IVUS/OCT/FFR
Structural procedures: TAVR, ASD/PFO closures, mitral
valvuloplasty, etc.
Specific CTO program since 2007. 80-90 procedures/year.
I am the main operator, performing approximately 60 CTO
procedures/year, with a personal experience of 350 cases
since 2007.

INDEX
1. Incidence
2. Classification
3. Mechanisms
4. Predictive factors
5. Material and techniques
6. Clinical outcomes
7. H. U. Bellvitge experience
8. Clinical cases

1. Incidence

n = 12729 coronary lesions in 7903 pat, 2004-2008
Hendry, et al. EuroIntervention 2012;7:79-86
Incidence (overall, non-CTO)

Incidence (overall, non-CTO)
Perforation incidence: 0.56% (44/12,729)

Incidence (CTO procedures)
Patel et al, J Am Coll Cardiol Intv 2013;6:128–36

2.9
0.3

Incidence (CTO procedures). Successful vs Unsuccessful

Incidence (CTO procedures). Temporal trends

Incidence (Retrograde CTO procedures)
El Sabbagh et al, Int J Cardiol 174 (2014):243–248

El Sabbagh et al, Int J Cardiol 174 (2014):243–248
Incidence (Retrograde CTO procedures)
n = 3482

Sianos G. CTO and LM Summit. New York 2014

2. Classification

Ellis Classification
Ellis et al. Circulation 1994;90:2725-2730.
I II
III

3. Mechanisms

Mechanisms
Guide - Wire
Perforation
(distal)
Balloon
Stent
Atherectomy
Rupture
(lateral)
Disruption of the vessel wall through
the intima, media and adventitia

Mechanisms
Javaid, Waksman et al. Am J Cardiol 2006; 98:911-914
n = 38559 PCI, 1996-2005
Perforation incidence: 0.19% (72/38559)

Mechanisms

Mechanisms Ellis III Perforation
Al-Lamee, Colombo et al. JACC Int 2011; 4:87-95
n = 24465 PCI, 1993-2009

4. Predictive Factors

Predictive Factors

Predictive Factors Ellis III Perforation
n = 24465 PCI, 1993-2009

Predictive Factors Summary
Guide-Wire distal-end stiffness
Hydrophilic coated wire (“spontaneous sliding”)
Older age
Female gender
Safenous vein
Severe calcification
High balloon stent-to-artery ratio. Postdilation
Atherectomy devices. Cutting balloon
CTO
High-pressure jet due to balloon rupture

5. Material and techniques

Stent Graft
Colombo et al. Cathet Cardiovasc Diagn 1996;38:172–174.
Romaguera et al. Catheter Cardiovasc Interv. 2011 Aug 1;78(2):246-53.
Autologous Vein-Covered Stents
Must be assembled
JOSTENT Graftmaster (Abbott)
PTFE sandwich 2 stents
Over and Under and Aneugraft
(ITGI Medical)
Pericardium covered stent

Stent Graft
Direct-Stent® (InSitu Technologies Inc.)
Low profile
Papyrus® (Biotronik)
Low profile

Moses. CTO and LM Summit. New York 2013
Stent Graft

Stent Graft
Papyrus® (Biotronik)
Low profile

Mesh Covered Stent
Romaguera et al. Catheter Cardiovasc Interv. 2012 Jul 1;80(1):75-8.
MGuard (InspireMD)

Subcutaneous fat
Blood clot
Coils
Particles: Microshperes / Gelfoam
Onyx
Thrombin
Glues
Embolization

Coils

Coils
Platinum polyester fiber coils
Compatible with PTCA over the wire balloons
or devices with 0.014 ID
Neuroradiology
Expensive

Embolization particles

Embolization particles
Sianos. CTO and LM Summit. New York 2014

Onyx

Thrombin: Radiotransparent. Can advance distally.
Glues (Gluebran): Can advance distally. Better with coils.
Refrigerator
Other embolizations

Management: Ellis I Perforation
Stent
Retrieval of guidewire
Wait and see
Usually no futher complications

Management: Ellis II Perforation
Prolonged balloon inflation (at or proximal)
Protamine (partially). Platelets ( IIb / IIIa)
Pericardiocentesis ?
Stent (Stent–Graft, M Guard) ?
Coils ?
High rate of only percutaneous management

Management: Ellis III Perforation
Prolonged balloon inflation (at or proximal).
Protamine (partially). Platelets ( IIb / IIIa).
Pericardiocentesis. Resuscitation measures.
Embolization (distal):
–Negative pressure suction via microcatheter
–Subcutaneous fat
–Blood clot
–Coils
–Onyx
–Particles: Microshperes (PVA) / Gelfoam
–Thrombin
–Glues
Stent Graft (lateral).
Emergent cardiac surgery.
Dramatic. Life threatening

Dual Catheter Technique for stent-graft implantation
Ben-Gal, Moses, et al. Catheter Cardiovasc Interv 75:708–712 (2010)

Management: Ellis IV Perforation
Wait and see.
Coils (distal).
Stent Graft (lateral).
Non emergent

6. Clinical Outcomes

Ellis et al. Circulation 1994;90:2725-2730.

Clinical Outcomes

Fasseas P et al Am Heart J 2004;147:140–5

Lance et al, JACC CI 2011;4:87

Clinical Outcomes
n = 24465 PCI, 1993-2009

Long-Term Clinical Outcomes
n = 24465 PCI, 1993-2009

Retrograde Approach: Perforation in the retrograde channel

Management Ellis III Perforation

www.bellvitgehospital.cat Moses. CTO and LM Summit. New York 2013

Always know where your wire is (or isn’t) especially
whether it is out of the vessel “architecture” or on a
sidebranch
As a corollary :don’t advance equipment unless it is
where you “hope” it is
Avoid oversizes balloons in calcified segments and
subintimal spaces (IVUS can help here)
Avoid atheroablation unless you are in the “true”
lumen
Perforations Avoidance

Watch Heart Borders
On Line Echo
Pan Over Whole Heart and Branches in Several
Views with completion angio
Perforations Detection

7. H. U. Bellvitge Experience

LEARNING CURVE

RESULTADOS: End points
Table 3. In-hospital angiographic and clinical outcomes. Procedural complications.
Pre-CTO Program
n=100 (CTO)
CTO Program
n= 350 (CTO)
p
In-hospital outcomes
Angiographic success, n (%) 49 (49.0) 325 (92.9) <0.001
MACE, n (%) 3 (3.0) 27 (7.7) 0.113
Cardiac death 0 0 N.A
Per-procedural MI 3 (3.0) 27 (7.7) 0.113
Ischemic-driven target vessel revasc. 1 (1.0) 0 0.323
CIN, n (%) 4 (4.0) 10 (2.8) 0.732
Procedural success, n (%) 48 (48.0) 288 (82.3) <0.001
Procedural complications
Coronary perforation, n (%) 14 (14.0) 13 (3.7) 0.004
Ellis III perforation, n (%) 1 (1.0) 2 (0,6%) 0.432
Cardiac tamponade, n (%) 1 (1.0) 0 0.323
Vascular access site complication, n (%) 6 (6.0) 9 (3.3) 0.511
CIN = contrast-induced nephropathy; CTO = chronic total occlusion; MACE = major cardiac event; MI = myocardial infarction; N.A =
not applicable.
49%
92,9%
0
10
20
30
40
50
60
70
80
90
100
Éxito angiográfico
No programa
Programa CTO
p<0,001

8. Clinical Cases

CASE 1: CTO Antegrade

Retrograde approach, CX epicardial channel, Sion and Corsair
Simple retrograde crossing with Gaia first, RG3 externalization

Fielder XTA but Finecross don´t cross. The system jumps

Coronary dissection and Ellis II perforation

Fielder XTA, Anchoring technique. Rotablator 1.25 mm burr

Progress 80 and Finecross. BHW exchange. Predilation and 3 x DES

Final result. Ellis II distal perforation. Protamine 25 mg

Final result. Normal echocardiogram

CASE 4: CTO Retrograde

Superselective injection with the channel dilator
in 2ª septal branch

RCA CTO. Progress 80, 200T and Confianza wires

Fielder XTR and Corsair. Septal perforation

First septal branch. Reverse CART

Reverse CART. Ellis II perforation

Final result. Two perforations

Ostial LAD CTO. Distal LIMA CTO

Septals channels. Marker wire. Antegrade wire

Retrograde aproach. Epicardial channel. Corsair don´t cross

Corsair in the channel. DES in proximal and mid LAD

RCA. Retrograde approach, epicardial channel from ramus intermedius
Sion wire and Finecross

Impossibility to advance the wire and microcath.
Gaia 2 and Corsair don´t advance

Corsair in the channel. Protamine 25 mg

CASES : non-CTO Ellis III perforations

Ellis III fat tissue embolization

Guiding and wire maneuvers needed to avoid deep intubation

Protamine 50 mg.
New TTE: no pericardial effusion

Infusion catheter (3F).
Embolization with autologous fat tissue.

Ellis III Particles PVA embolization

Hypotension.
Tamponade checked by TTE.

Pericardiocentesis+protamine+balloon dilation for 11 min.
Current ACT: 120 seg

Control after protamine+balloon.

Platelet+blood transfusion
Polivynil-OH microparticles through an inflated 1,5 OTW balloon

Good evolution. Small AMI. 48h TTE: no effusion

Ellis III Coils embolization

Ellis III Graft Stent

Graft Stent 4.0 x 12 mm; 4.0 x 9 mm; 3.5 x 12 mm; 3.5 x 9 mm

Ellis III Mesh Covered Stent

After prolonged balloon inflations

Treatment of Coronary Perforations

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Editor's Notes