presentation about management of coronary artery perforations

1. PRESENTOR: DR. ABHISHEK

2. 
 Incidence
 Causes and mechanisms
 Classifications
 Management
Learning objectives

3. 
 Coronary artery perforation is defined as
extravasation of contrast/blood from coronary
artery, during or after PCI.
 Incidence range from 0.19% to 3% with 13x increase
in hospital mortality and 5x rise in 30 day mortality
 Risk of temponade is 0.3%.
INTRODUCTION

4. 
 Ellis and colleagues described the first series of 12900
pts from 1990 and 1991.
 Incidence was 0.5%
 Incidence of temponade in type I CAP was 8%
 63% of type III CAP developed temponade with
mortality of 19%.
 Female gender and increasing age were predisposing
patient characteristics.
INITIAL DATA

5. 
 Subsequent meta-analysis of 16 studies involving
197061 cases reported:
 Incidence – 0.43%
 Mortality and cardiac temponade incidence: type I,
0.4% and 0.35; type II, 3.3% and 0.4%; type III, 45.7%
and 21.2%, respectively
 Type III were associated with high long term MACE
rates.

6. 

7. 

8. 

9. 

10. 
 NON MODIFIABLE
 Old age
 Female gender
 Previous CABG
 Use of clopidogrel
 MODIFIABLE
 Hypertension
 Peripheral artery disease
 Congestive heart failure
RISK FACTORS

11. 
 Low BMI
 Lower creatinine clearence
 RISK ASSO. WITH CORONARY ANATOMY
 Complex leisions(ACC/AHA Type B2,C)
 CTO, calcification, angulation, tortuosity
 Oversized balloons, stents
 Atheroablative device use, hydrophilic guidewires

12. 
 A. VESSEL RUPTURE
 1. Stent/Balloon mismatch (balloon:artery> 1.2:1)
 2. Lack of vessel wall integrity
 3. subintimal wire placement
 4. atherctomy devices
 B. GUIDEWIRE PERFORATIONS
Mechanisms

13. 
 1. ANATOMICAL CLASSIFICATION
 Large vessel
 Distal vessel
 Collateral :
 Septal
 Epicardial
Classification(s)

14. 
 2. ELLIS CLASSIFICATION

15. 

16. 
 FUKOTOMI
 Type I: Epicardial staining without contrast
extravasation
 Type II: Epicardial staining with a visible jet of
contrast extravasation
 KINI
 Type I: Myocardial staining without contrast
extravasation
 Type II: Contrast extravasation into pericardium,
coronary sinus or cardiac chambers

17. 
 High index of suspicion
 Clinical clues
 Hypotension , severe chest pain, nausea, ST segment
changes, vasovagal with severe bradycardia and
hypotension
 Late temponade as late as 24 hrs post PCI reported
 Prognosis depends on severity of perforation as well
as other risk factors
 CTO PCI, perforation is associated with a 7.1% rate
of death and 25.9% rate of major adverse cardiac
events (MACEs)
Diagnosis and prognosis

18. 
 GENERAL MANAGEMENT
A. BALLOON INFLATION:
1. Proximal or at perforation site immediately, should
be of same size of vessel, semi compliant and inflated
to not more than 8-10 atm.
2. Inflation is prolonged atleast 10-15 min
3. May seal small perforations on itself particularly Ellis
I/II
Management

19. 
 BALLOON INFLATION TYPES
 1. Persistent complete occlusion
 Not feasible as >20 min of total occlusion time is
unacceptable for humans
 Thrombus may not be mature sufficiently to occlude the
vessel
 Anticoagulant effects of heparin could not be reversed as
protamine cannot reach the perforation site

20. 
 2. Persistent partial occlusion
 No current reports available.
 Theoretically possible
 MAP should be maintained at 50-65 mmhg and for
hypertensive patients MAP should be controlled at
30% below baseline
 FFR <0.4, ∆P >60 mmhg; for creation of 90% stenosis.
 Goal is TIMI grade 2 flow

21. 
 3. Intermittent complete occlusion
 Most commonly used method
 “Ischemic preconditioning (IPC)”; nonfatal complete
ischemia found to improve tissue tolerability to
reperfusion injury after long-term ischemia and to
delay cell death.
 The protection of IPC can be divided into two time
phases: early and late.
 Early IPC phase occurs within the first 2-3 hrs after an
ischemic event

22. 
 Late phase occurs between 12–24 hrs and 48–72 hrs.
 If cardiac surgery is unavoidable for patients with
pericardial tamponade, the best time window is within
3 hrs after balloon occlusion, when the protective
effect of IPC is maximal.
 A 10 min ischemia/ 1 min reperfusioin model is
optimal
 May not be satisfactory in patients with cardiac
diseases
 5min/5min model can be used in such patients.
 4. Intermittent partial occlusion.

23. 
B. SECURE ARTERIAL ACCESS
• Second access needed if guide catheter used is not 8F,
as additional bulky instrument may be needed.
C. I/V FLUIDS AND VASSOPRESSORS/ATROPINE
D. PERICARDIOCENTESIS:
 Timing guided by hemodyanamics, urgent if
hemodyanamic instability,
 Small effusions may be managed conservatively.
E. Notify surgical team

24. 
 ANTICOAGULATION REVERSAL
 Should be deferred till all interventional equipments
are removed, and pericardiocentesis done .
 Carries risk of stent thrombosis, pericardial blood
coagulation
 ACT should be kept <150 s
 Protamine 1mg/1oo units of UHF max 50mg rate
<5mg/min, is used for heparin reversal.
 IIb/IIIa inhibitors should be discontinued

25. 
 CAUSES
 Oversized stents, high pressure balloon inflations, sp
in heavily calcified arteries
 Balloon ruptures
 Atherectomy
 Guidewire exit followed by inadvertent equipment
advancement
Large vessel perforation

26. 
 TREATMENT
 Balloon inflation
 Covered stents
 Single guide: block and deliver technique
 Double guide: ping pong technique
 Prolonged balloon inflations if covered stents not
available
 Surgery
 Dissection technique

27. 
 COVERED STENTS
 Most widely used is PTFE covered stent,(Graftmaster)
sandwich design, PTFE layer in between two BMS.
 Inflexible, difficult to deliver
 Bulky and require special guide techniques, excellent
support.
 Require aggressive post dialatation to achieve good
expansion, > 20 atm
 Side branch exclusion may cause periprocedural MI

28. 
 IVUS used to confirm proper deployment and
expansion
 Edge dissections should be ruled out and has to be
covered with additional stents
 High rate of restenosis and 22% 1 year MACE
reported with covered stents.

29. 
 GRAFTMASTER
 Consists of two stainless steel stents with a middle
layer of ePTFE.
 Bulky and difficult to deliver; hence excellent guide
catheter support is important.
 Available in diameters of 2.8 to 4.8 mm and lengths
between 16 and 26 mm
 Requires a 6 French guide catheter for the 2.8 to 4.0
mm stents and a 7 French guide catheter for the 4.5
and 4.8 mm stents

30. 
 Graftmaster Rx may be difficult to advance through
previously deployed stents, necessitating techniques
such as distal anchor and use of a guide catheter
extension
 Minimum inflation pressure is 15 atm, but even higher
pressures for up to 60 seconds (and use of
intravascular ultrasound) are preferred to ensure
adequate stent expansion.
 After expansion the stent may shorten up to 1.6 mm
on each side (for a total of 3.2 mm at nominal pressure,
which is 15 atm).

31. 
 Use of a dual catheter (“ping-pong guide”) technique
is often required,
 Postdilation of the shoulders of the stent may be
necessary to fully appose the stent to the vessel wall
if extravasation persists behind the stent despite
covering the perforation.

32. 
 PK PAPYRUS
 Covered coronary stent system is a balloon-
expandable covered stent mounted on a rapid-
exchange delivery catheter
 Device size matrix ranges from 2.5 to 5.0 mm stent
diameters and lengths of 15, 20, and 26 mm
 Papyrus stent may be postdilated to a maximum stent
expansion diameter of 3.50 mm for the 2.5 and 3.0 mm
stents; 4.65 mm for the 3.5 and 4.0 mm stents; and 5.63
mm for the 4.5 and 5.0 mm stents.

33. 
 Compatible with 5 French guiding catheters for
diameters 2.54 mm and 6 French for diameters 4.5 and
5.0 mm
 Easier to deliver compared with the Graftmaster but
can occasionally be dislodged from the balloon during
attempts to deliver it to the perforation site,

34. 

35. 

36. 
Catheter techniques

37. 
SINGLE GUIDE CATHETER TECHNIQUE

38. 
DOUBLE GUIDE CATHETER TECHNIQUE

39. 
 Difficult to diagnose, as they are small, specially
when collimation is used to reduce radiation.
 Temponade may develop late, therefore require
monitoring and serial echo,
 Gp Ib/IIIa inhibitors should not be given.
 Covered stents may not be required.
 Generally small concern of ischemia
DISTAL VESSEL PERFORATION

40. 
 CAUSES
 Inadvertent advancement of guidewires, balloon,
microcatheter into a distal vessel
 Stiff, tapered and polymer jacketed wires more likely
 PREVENTION
 Attention to guidewire position during equipment
delivery or when using multiple guidewires
 Exchange jacketed wire with workhorse wire

41. 
 TREATMENT
 1. Balloon inflation: balloon inflated proximally to
stop bleeding into pericardium, pericardiocentesis
may be done if hemodynamic compromise
 2. Assess for continued bleeding: after balloon
inflation if no bleeding, heparin reversed after taking
out all instruments,
 Suction through a microcatheter may collapse vessel
and stop bleeding
 3. Covered stent or Embolization

42. 
 EMBOLIZATION
 Commonly done using FAT or COIL
 Fat is preferred in most cases except in large
perforations, as it is universally available, low coast
and biologically compatible
 Delivery is not as controlled as for a coil.

43. 
 BASIC STEPS
 1. Temporarily balloon deflation and second
guidewire advancement
 2. Balloon reinflation
 3. Balloon deflation and microcatheter delivery
 4. Balloon reinflation and localization of perforation by
giving contrast through microcatheter
 5, Embolization

44. 
 Choosing the microcatheter
 Fat can be delivered through any microcatheter
 For coil appropriate choice of the microcatheter is
important
 Most coils available are compatible with 0.018 in.
microcatheter and can not be delivered through 0.014
in. catheters
 Nneurovascular coils compatible with 0.014 in.
catheters are available.

45. 
Microcatheters and their compatibility with the “Block
and Deliver” technique using guiding catheters of
different diameters.

46. 
Advantages and disadvantages of fat versus coil
embolization for treating distal coronary perforations

47. 
 Fat can be harvested by advancing a hemostat into
femoral arteriotomy site, larger pieces cut into
smaller by scalpel.
 Fat dipped into contrast for 1 min to make it
radiopaque
 Loaded into microcatheter and the hub is turned
upside down to facilitate loading.
 Fat injected by flushing with saline.
 Several pieces may be required
FAT EMBOLIZATION

48. 

49. 
 Coiling is very infrequent in the cardiac
catheterization laboratory, achieving familiarity with
how to deliver and deploy a coil before a
complication occurs can significantly facilitate
management.
 Coils are usually made of stainless steel or platinum
alloys and some of them have polymers or synthetic
wool or dacron fibers attached along the length of
the wire to increase thrombogenicity.
COIL EMBOLIZATION

50. 
 Once advanced into the target vessel, the coils
assume a preformed shape, sealing the perforation.
 Particular attention needs to be made when coiling
branches to prevent the coil from prolapsing into the
main vessel.
 Having only one or two types of coils is sufficient

51. 
 There are two broad categories of coils according to
mechanism of release: pushable and detachable
 Pushable coils are inserted into a microcatheter and
pushed with a coil pusher or the front end of a
guidewire until they exit into the vessel, hence
deployment can be unpredictable and is irreversible
 Detachable coils are released using a dedicated
release device once their position into the target
vessel is confirmed; conversely if their position is not
satisfactory, they can be retrieved.

52. 
 There are also two broad categories of coils
according to the size of the delivery microcatheter.
 Coils compatible with 0.018 in. microcatheters (such
as the Interlock [Boston Scientific], Azur [Terumo],
and Micronester [Cook]), cannot be delivered
through the standard microcatheters used during
CTO PCI with the exception of the Finecross, and
require change to a larger microcatheter, such as the
Progreat (Terumo), Renegade (Boston Scientific), or
Transit (Cordis).

53. 
 Coils compatible with 0.014 in. microcatheters (such
as Axium, Medtronic) are preferred, as they can be
delivered through the standard microcatheters used
for CTO PCI

54. 
 When the perforated vessel is too small or too
tortuous, advancing a guidewire into it may not be
feasible
 Such cases could be treated with coiling of a more
proximal larger branch, but if the perforated vessel is
originating from a large vessel, occlusion of that
vessel can be undesirable
 Alternative solution is implantation of a covered
stent over the origin of the perforated branch
COVERED STENTS

55. 

56. 
 Perforation of an epicardial collateral branch is a
serious complication of retrograde CTO PCI, as it can
rapidly lead to tamponade and may be particularly
difficult to control
 Perforation of septal collaterals is unlikely to have
adverse consequences, although septal hematomas
and even tamponade have been reported
COLLETERAL VESSEL PERFORATION

57. 
 Incidence upto 6.9% in a single case series in patients
with a retrograde approach
 Septal hematomas have caused asymptomatic
bigeminy and severe chest pain, appear as an echo-
free space in the interventricular septum on
transthoracic echocardiography and resolve
spontaneously.
 Perforation into a cardiac chamber usually does not
cause complications.
SEPTAL COLLATERAL PERFORATION

58. 
 CAUSES
 Aggressive septal guidewire crossings, specially a
microcatheter.
 Selection of a very thin or torturous septal channels
 Dilation of the septal channel
 PREVENTIONS
 Selection of adequate septal channel.
 Caution with tip injection of contrast if wedged
position of microcath is suspected

59. 
 Avoid advancement of Crosair microcath untill
guidewire position has been ascertained
 Equipment retrival after recanalization should be done
after collateral perforation has been ruled out
 TREATMENT
 Usually no treatment required
 Advancing microcath usually stop bleeding
 Negative pressure from wedged microcath
 If temponase , coiling to be done.

60. 
 Riskier than septal collateral perforation, as it can
rapidly lead to tamponade.
 Epicardial collateral wiring is not safer in patients
with prior CABG surgery as loculated hematoma can
occur
 CAUSES
 Aggressive guidewire and microcath advancement
EPICARDIAL COLLATERAL
PERFORATION

61. 
 PREVENTION
 In contrast to septal collaterals, epicardial collaterals
should never be dilated.
 Avoid microcath advancement in front of wire
 TREATMENT
 General perforation treatment
 Balloon temponade and negative pressure from the
wedged microcath.
 Embolization/coiling: should be on both sides of the
perforation

62. 

63. 
 In the past prior coronary bypass graft surgery was
considered protective from tamponade in patients in
whom perforation occurs
 Loculated effusions can develop in these patients
that can compress various cardiac structures such as
the left atrium or the right ventricle
 Such loculated effusions can be lethal, as they can be
impossible to reach and drain percutaneously
 Therefore, perforations in prior CABG patients
should be immediately treated
Perforations in post CABG cases

64. 

65. 

66. 
Take home message
 CAP are potentially fatal but avoidable complications of
PCI
 The incidence is fairly low
 Can be avoided with careful handling of equipments
specially during complex interventions
 High lndex of suspicion is the key
 Stop the bleeding first
 Prolonged balloon dilatation is always indicated
 Worse outcomes if emergency surgery is needed.

67. 