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Complication management 3
- 1. CTO-PCI Complications Management: Case Based Prof.Dr.Sami Özgül KSU Medical faculty Cardiology department 14uccvs
- 2. Complications of PCI RecognitionPrevention Management The Basics 14uccvs
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- 5. CTO PCI specific complications 1.Occluded artery • Perforation • dissection 2. Colleterals • rupture/hematoma of the septal colleterals • perforation to the RV/LV • rupture/perforation of the epicardial colleteral 3. Epicardial flow disruption with ishcemia 14uccvs
- 6. 4. Donor artery • spasm • dissection/thrombosis 5..Entrapment of wire/ device 6. Aortic root dissection 7. CIN 8. Radiation 14uccvs
- 7. Useful kit to have on hand • Occlussive balloons • Coils • Subcutaneous fat • Covered stent • Cell saver device • Pericardiocentesis kit 14.UCCVS/64.ESCVS
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- 9. Ocluded artery perforation- Dissections 14uccvs
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- 12. • Type 1 perforation • management • Watchful Wait 14uccvs
- 13. Type 2-3 perforation management Main vessel perforation Distal vessel perforation Colleteral vessel perforation Prolonged balloon inflation Cardiac tamponade-echo Pericardiocentesis kit Pressors Access left femoral:2nd Guiding catheter PTFE stent Reverse anticoagulation 14uccvs
- 14. Type 2-3 Perforation management Distal vessel perforation: Embolization: gelfoam coils blood clot subcutaneous fat Prolonged aspiration:microcatheter 14uccvs
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- 16. Predilation – balloon rupture next step? TIP: Balloon rupture can cause perforation TIP: When a balloon ruptures do an angiogram immediately! 14uccvs
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- 24. Balloon rupture during postdilation Unable to deliver covered stent
- 25. After hours of ballooning More balloon inflations...
- 26. 3 hours later: wire removed then protamine given •If unable to deliver covered stent, prolonged balloon inflation can achieve hemostasis •Heparin reversal should be delayed until after equipment removal from coronary arteries
- 27. Tip 3: Echo contrast to confirm sealing
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- 34. Septal Channel Rupture • Usually small and contained by myocardium causing a small, asymptomatic hematoma that will be absorbed • However, if the hematoma is large and/or symptomatic, sealing or occlusion may become necessary 14uccvs
- 35. Septal Cavitary Hematoma Secondary to ruptured septal collaterals at retrograde gear removal
- 36. Rapidly expanding Septal Cavitary Hematoma Right Ventricle Outflow Tract Obstruction Trace Pericardial Effusion Cavity is now 3x bigger than at end procedure in the cath lab HD under no pressors: CVP: 13 mmHg PA: 30/19 (22) mmHg Ao: 131/68 mmHg HR: 90 bpm regular PA Sat: 52% Decision made to return to Cath Lab
- 37. TTE 05-09-2017 Large hematoma (at least 3 cm) Of the mid and Basal inferior septum which in some views impinges on the RV cavity
- 38. Last TTE Images 05-17-2017 Hematoma slowly getting smaller with little residual RV cavity impingement
- 39. Septal thrombus
- 40. 14uccvs
- 41. Complications Specific to the Retrograde Approach • Channel rupture • Potentially Overwhelming Ischemia from donor artery dampening or flow-limiting dissection • Thrombosis of the Donor Artery • Prolonged Ischemia while Instrumenting a Dominant Collateral Channel 14uccvs
- 42. • Colleteral perforations do lead deleterious outcomes and should be dealt with aggressively • Operators must ,above all,avoid perforation with careful colleteral selection • Several options exists to seal perforations • 14uccvs
- 43. Lessons 1. Perforation: Universal algorithm 2. Know your covered stents 3. Prolonged balloon inflations 4. Do not reverse heparin 5. Prior CABG: treat early! 14uccvs
- 44. Reason for perforation • Stiff guidewire • Oversize balloon,stent • Retrograde access • Predilation Baloon rupture 14uccvs
- 45. Prevention for perforation • Carefull manipulation of guidewire • Correct reading angiogram • IVUS,MSCT guide 14uccvs
- 46. • Aortic root dissection 14uccvs
- 47. Iatrogenic coronary aorto dissection cause • Guide catheter trauma • Injection of contrast:wedged catheter • Balloon rupture • Retrograde progression RCA dissection 14uccvs
- 48. Iatrogenic aortic dissection Dunning Clasification • Class definition • 1. limited to ipsilateral coronary cusps • 2. cusps –prox.ascending aorta (<40mm) • 3. cusps to aortic arch (>40mm) 14uccvs
- 49. • Manegement • Type 1 and 2 dissection • Minimise contrast injection • Reverse anticoagulation • Consider 5 f child catheter • Stent intracoronary entry point dissection • conventional stent • covered stent • assess progresssion:TEE 14uccvs
- 50. • Coronary aorto dissection • manegement • Type 3 Dissection • Surgical intervention 14uccvs
- 51. Class 1 Dissection Into the Right Coronary Cusp Successfully Treated with Stent Implantation Dunning et al Cathet. Cardiovasc. Intervent. 51:387, 2000. 14uccvs
- 52. Class 2 Dissection Extending Into the Aorta with RCA Occlusion Requiring CABG Dunning et al Cathet. Cardiovasc. Intervent. 51:387, 2000. 14uccvs
- 53. Class 3 Dissection Extending Into the Aortic Arch often with Fatal Outcome 14uccvs
- 55. It’s Often About Fracture Points 14uccvs
- 56. 14uccvs
- 57. Causes Bail-out techniques Trapped equipment Wires Prolapsed or knuckled wire is trapped in a calcified or tortuous segment Wire used to protect a side branch is trapped behind a newly deployed stent Advance microcatheter or over-the-wire balloon to provide controlled, local traction at the site of entrapment. Advance the microcathter beyond the highest point of resistance, and the wire can then be removed. Knotted wires During aggressive wire ‘knuckling’ or excessive torquing, a knot can be formed Advance a microcatheter to the point where the wire is knotted and gently pull on the wire to untangle it
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- 59. Rota-burr Small Rota burr is advanced too quickly past a lesion and cannot be withdrawn Rota burr is embedded into a calcified lesion or within a previously placed stent Apply gentle negative pressure while using Dynaglide Use ‘mother-in-child’ guide or gooseneck snare as above. Advance a parallel wire and perform angioplasty of the culprit region Pull on the RotaWire while pulling on the burr Wires Wire trapped in small tortuous collateral Use a microcatheter to relieve the resistance on the wire, as above Retrograde scenarios Causes Bail-out techniques 14uccvs
- 60. Balloons and microcatheters Collateral is small and tortuous, has a sharply angulated takeoff, or is jailed by a stent Remove the externalized wire from the microcatheter to allow it to become more pliable and conform to the tortuous vessel, then remove the microcatheter Use ‘mother-in-child’ guide or gooseneck snare as above. Entanglement of antegrade and retrograde gear Tips of the antegrade and retrograde microcatheters become coupled Pull both catheters from their proximal extremities Cut off antegrade device hub and pull back on the retrograde equipment, pulling out all the gear through the collateral and out the retrograde guide causes Bail-out techniques
- 61. Embolized equipment Wires, stents, and microcatheter tips Entrapped portion of device fractures during attempt to withdraw device Aggressive or careless wire advancement causes the wire tip to prolapse and fracture Calcifi ed/tortuous lesion causes the delivery balloon to separate from the stent Micro snare retrieval Entangle the fragment with 2 or 3 wires and remove Advance a small balloon or protection device/basket distal to the fragment and drag back Biopsy forceps can be used for devices in proximal coronaries Stent the fragment into the vessel wall
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- 67. Retained Balloon Case 1. Increase support: amplatz the guide, guideliner, anchor balloon 2. Small balloon (1.5mm X 20mm) inflations for pre-dilation 3. BAM 4. Switch to smaller profile microcatheter (micro 014, etc) 5. Switch to stiffer microcatheter (Turnpike gold) to dotter lesion 6. Laser atherectomy 7. External cap crush 8. Carlino 9. Use micro 014/Finecross microcatheter to deliver a short roto wire and perform rotational atherectomy 10. Go retrograde (retrograde external cap crush) Crossboss won’t deliver 14uccvs
- 68. Retained Balloon Case Stingray won’t deliver 2.0 Apex burst balloon pieces 14uccvs
- 69. Retained Balloon Case Case report from Hartzler from 1986 utilizing systemic anticoagulation
- 70. Retained Balloon Case Snares in Guides from the CFA and radial access sites: JR AL1 IM MPA Hockey Stick CTS- not a surgical candidate (sternotomy X2, TMR, etc) 14uccvs
- 71. Lost Roto Burr Case
- 72. Lost Roto Burr Case
- 73. Lost Roto Burr Case
- 74. Lost Roto Burr Case
- 75. Stent Lost Off Balloon Case
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- 78. • Lost intracoronary gear is rare event but has potential sinificance consequences • Stabilize the patient first and give yourself time to think/ phone a friend • Multiple different ways to remove gear all of which are significantly improved with the retention of the wire position If possible 14uccvs
- 79. • Contrast induced nephropathy 14uccvs
- 80. • Calculate eGFR (creatinin clearance): • Risk is increased if eGFR is less than 60ml/min/1.73m2 • Check diabetic status:risk is fivefold higher in diabetic patients • Discuss CIN risk in informed consent process • Discontuinue nonsteroidal anti inflamatory drugs and other renal toxic drugs 14uccvs
- 81. • Arrange nephrology consult for eGFR less than 15ml/min/1.73m2 for dialysis planning after PCI • Hydration with normal saline or ½ saline or sodiumbicarbonate 150ml/h 3 hours before 6 hours after procedure • Ensure urine flow rate greater than 150ml/h after PCI 14uccvs
- 82. • Iodixanol is the preferred contrast agent • limit contrast volume to less than 100ml • Administer N acetylcysteine 600 mg 14uccvs
- 83. Acute non-coronary complications of CTO PCI: • Contrast induced • Calculate maximal recommended contrast dose(MRCD) prior CTO procedure • • MRCD=5ml of contrast x body weight/serum creatinin • Check LVEDP prior to CTO PCI with CKD to assess hydration status • Consider aborting procedure if CTO not crossed and you are close to MRCD • 14uccvs
- 84. Avoidance of CIN • Awareness of risk factors • Optimize pre procedure creatinine , • Hemodynamics • Use NAC,Bicarb drop • Appropriate contrast volume • Flouroscopic/guidewire clues • Microcatheter contralateral injections • Biplane • IVUS 14uccvs
- 87. 30 days 16-21 weeks depigmentation and atrophy 3-6 months ulceration
- 88. Prevention of Radiation Dermatitis • Alert to staged procedures • Knowledge of previous fluoro times • Physician alerts at 2 Gy intervals • >5 Gy skin dose – Patient education regarding radiation exposure – Skin monitoring and skin care – Documentation of patient – Notification to PCP • > 10 Gy or > 50 min fluoro time – Consider aborting the procedure • >15 Gy is “Sentinel Event” reported to Dept of Health
- 89. “Sometimes I feel if I don’t get complications, then I am not trying hard enough” Antonio Colombo Hawaii, 1997 14uccvs
- 90. 14uccvs
Editor's Notes
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