This document discusses complications that can occur during percutaneous coronary intervention (PCI) and provides tips for managing them. It begins by classifying PCI complications into coronary (vessel closes or leaks, equipment in wrong place), heart (myocardial infarction, arrhythmia, tamponade), and other (access, thromboembolic, contrast, radiation). Specific tips are then provided for managing perforations including using a covered stent or coils. The document emphasizes being prepared for complications and having a plan, as well as communicating with the medical team to resolve issues promptly.

1. Emmanouil S. Brilakis, MD, PhD
Minneapolis Heart Institute
A brief review of
complications and 18 tips
and tricks
14.50-16.05
Euro CTO Club 2017
September 16, 2017

2. Disclosures
Consulting/speaker honoraria: Abbott
Vascular, Amgen, Asahi, CSI, Elsevier,
GE Healthcare, Medicure
Employment (spouse): Medtronic
Grants: Boston Scientific, Osprey
VA CSP#571 – DIVA

3. CORONARY
1. Vessel closes
• Dissection
• Embolization
• Spasm
• Pseudolesion
2. Vessel Leaks
• Perforation
3. “Wrong place”
• Equipment loss
PCI complications: a classification
HEART
1. MI
2. Arrhythmia -
arrest
3. Tamponade
OTHER
1. Access
2. Thromboembolic
3. Contrast
• Nephropathy
• Allergies
4. Radiation

4. CORONARY
1. Vessel closes
• Dissection
• Embolization
• Spasm
• Pseudolesion
2. Vessel Leaks
• Perforation
3. “Wrong place”
• Equipment loss
PCI complications: a classification
HEART
1. MI
2. Arrhythmia -
arrest
3. Tamponade
OTHER
1. Access
2. Thromboembolic
3. Contrast
• Nephropathy
• Allergies
4. Radiation

5. Dual
injection

6. True to true
crossing
into aorta

7. Chest pain
and
hypotension

8. LAD wiring
and balloon
TIP 1
Insert “safety wire” into
donor vessel during CTO PCI

9. Stent placed in
LAD over
retrograde
guidewire
(microcatheter
removed)

10. Final LAD

11. CORONARY
1. Vessel closes
• Dissection
• Embolization
• Spasm
• Pseudolesion
2. Vessel Leaks
• Perforation
3. “Wrong place”
• Equipment loss
PCI complications: a classification
HEART
1. MI
2. Arrhythmia -
arrest
3. Tamponade
OTHER
1. Access
2. Thromboembolic
3. Contrast
• Nephropathy
• Allergies
4. Radiation

12. Survey of 1,149 cardiologists on CTO PCI
Patel S, Menon RV, Burke MN, Jaffer FA, Yeh RW, Vo M, Karmpaliotis D, Azzalini L, Carlino M, Mashayekhi K, Galassi A, Rinfret S, Ellis S, Patel M, Rangan
BV, Karatasakis A, Danek BA, Karacsonyi J, Resendes E, Banerjee S, Brilakis ES. J Invasive Cardiol. 2017; in press

13. Types of coronary perforation
Main Vessel
perforation
Distal Wire
perforation
Collateral
perforation

14. Brilakis ES. Manual of coronary CTO interventions 2nd edition. Elsevier 2017
Sealing a large vessel perforation
TIP 2
Have a plan!

15. Brilakis ES. Manual of coronary CTO interventions 2nd edition. Elsevier 2017
Sealing a large vessel perforation

16. LAD CTO

17. Predilation
– balloon
rupture
next step?
TIP 3
Balloon rupture
can cause
perforation
TIP 4
When a balloon ruptures do
an angiogram immediately!

18. “Universal” Algorithm for
Coronary Perforations
Type-specific
Treatment
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}

19. Stop
bleeding
TIP 5
The first step in any
perforation is to inflate a
balloon proximally to stop
pericardial bleeding

20. Graftmaster Rx
• HDE - IRB approval needed
• 2.8 - 4.0 mm stents: 6 French guide
• 4.5 and 4.8 mm stents: 7 French guide
Brilakis ES. Manual of coronary CTO interventions. Elsevier 2013

21. Ping-pong

22. Unable to
deliver
2.80x19 mm
Graftmaster
TIP 6
Delivery of covered stents
can be very challenging

23. Covered
stent
through
Guideliner
TIP 7
Graftmaster stents can fit
within an 8 Fr Guideliner

24. Perforation
sealed

25. ACT=227
TIP 8
Perforation can be further
complicated by thrombosis
DON’T REVERSE HEPARIN UNTIL
AFTER EQUIPMENT REMOVED
FROM CORONARY ARTERY

26. Final result

27. TTE at the end
TIP 9
Early balloon inflation can
prevent tamponade

28. Types of coronary perforation
Main Vessel
perforation
Distal Wire
perforation
Collateral
perforation

29. Brilakis ES. Manual of coronary CTO interventions 2nd edition. Elsevier 2017
Distal vessel perforation

30. Brilakis ES. Manual of coronary CTO interventions 2nd edition. Elsevier 2017
Distal vessel embolization
Block and deliver

31. Brilakis ES. Manual of coronary CTO interventions 2nd edition. Elsevier 2017
Covered stent for distal perforation 1

32. Brilakis ES. Manual of coronary CTO interventions 2nd edition. Elsevier 2017
Covered stent for distal perforation 2

33. Coil vs. fat embolization
Fat Coil
Visibility 0 +
Controlled delivery 0 +
Catheter needed
for delivery
Any microcatheter Larger microcatheter*
Availability Universal Often limited
Cost 0 High

35. A C
B D
TIP 10
Fat floats!

36. RCA CTO

37. Distal vessel
perforation

38. “Universal” Algorithm for
Coronary Perforations
Type-specific
Treatment
}
}

39. Currently used coils in our lab
Axium – ev3 Azur – Terumo
Finecross 1.8 Fr Progreat 2.8 Fr
Tip 11
Learn your coils

40. Block +
Deliver

41. Coil 3

42. Bleeding
continues
Tip 12
Bleeding may not
stop immediately
after coiling

43. Bleeding
stopped
(finally…)

45. TIP 13
Contrast echo to
ensure pericardial
bleeding has stopped

46. TIMELINE
6 years prior
2.5x32 mm and 3.0x16 mm DES to
pRCA
1.5 years prior
2.5x24 mm DES to mRCA
1 year prior
POBA mRCA
6 months prior
3.0x38 mm DES and a 3.5x38 mm
DES
Now
mRCA severe ISR

47. Now what?
“Universal” Algorithm for
Coronary Perforations

48. Attempted to
wire perforated
branch with
Fielder FC wire
over a Transit
microcatheter
with intent to
perform fat-
embolism
“Block and deliver”

49. 2.8x19 mm Graftmaster covered stent delivered next to
balloon through a single 8 Fr guide catheter
“Block and deliver”Tip 14
Covered stent can
be used for distal
vessel perforation

50. Types of coronary perforation
Main Vessel
perforation
Distal Wire
perforation
Collateral
perforation

51. TIP 16
Epicardial collateral
perforation requires sealing
from both sides

52. Brilakis ES. Manual of coronary CTO interventions 2nd edition. Elsevier 2017
Sealing an epicardial collateral perforation

53. Wilson et al. CCI 2015;86:407–41
TIP 17
Perforation in the post
CABG patient can be a
lethal complication –
TREAT IT IMMEDIATELY!

54. CORONARY
1. Vessel closes
• Dissection
• Embolization
• Spasm
• Pseudolesion
2. Vessel Leaks
• Perforation
3. “Wrong place”
• Equipment loss
PCI complications: a classification
HEART
1. MI
2. Arrhythmia -
arrest
3. Tamponade
OTHER
1. Access
2. Thromboembolic
3. Contrast
• Nephropathy
• Allergies
4. Radiation

55. Retrieve
Do not
retrieve
•Deploy
•Crush
“Attempts at removal may make
things worse”
“Retrieval approaches require
imagination, creativity, flexibility and
excellent visualization” David R. Holmes, Jr, MD
Stent Loss
Treatment
Tip 18
You don’t always
have to retrieve a
lost stent

56. Stent retrieval: small balloon technique
Brilakis, Garratt. Strategic Approach to coronary interventions 2005

57. Conclusions
1. Know what can go wrong and what you
can do about it
2. Closure: Safety wire in donor vessel’
3. Perforation “Universal Algorithm” +
covered stents + fat + coils
3. Stent/devive loss: you don’t always have
to retrieve
4. Remain calm – communicate with team
Available: TCT 2017
www.progresscto.org
www.ctomanual.org