This document discusses the treatment of coronary perforations during percutaneous coronary intervention (PCI) for chronic total occlusions (CTOs). It notes that while coronary perforations are common in CTO PCI, most do not have serious consequences. It then discusses risk factors, classification systems, and specific approaches to treating different types of perforations including main vessel, distal artery, and collateral vessel perforations. Two clinical cases are presented involving perforations during CTO PCI and the management in each case, including the use of covered stents, coils, pericardiocentesis, and in one case emergency surgery. General measures for managing perforations are also outlined.

1. J Escaned Treatment of coronary perforations Istanbul 2015
EURO CTO CLUB 7th Experts "Live" Workshop September, 18th – 19th, 2015
Treatment of coronary perforations
Javier Escaned MD PhD
Hospital Clínico San Carlos.
Madrid. Spain.
Istanbul 2015

2. J Escaned Treatment of coronary perforations Istanbul 2015
Some considerations about CTO in ISR
• Although coronary perforations are common in CTO PCI
(27.6% in one series 1), most perforations do not have
serious consequences, and the risk of tamponade is low,
approximately 0.3%.
• At a difference with PCI in non-CTOs, controlled occlusion
of perforated vessel in CTO PCI usually does not cause
myocardial ischemia, allowing for testing sequential
strategies, preparing hardware, etc.
1 Rathore S et al JACC Cardiovasc Interv 2009;2:489-97

3. J Escaned Treatment of coronary perforations Istanbul 2015
Risk factors for coronary perforations
in CTO PCI
• Anatomy related factors
• Medication related factors
• Device and technique related factors

4. J Escaned Treatment of coronary perforations Istanbul 2015
Ellis classification of coronary perforations
• •Class 1: a crater extending outside the lumen only in the
absence of linear staining angiographically suggestive of
dissection
• •Class 2: Pericardial or myocardial blush without a ≥1 mm
exit hole
• •Class 3: Frank streaming of contrast through a ≥1 mm exit
hole
• •Class 3-cavity spilling: Perforation into an anatomic cavity
chamber, such as the coronary sinus, the right ventricle, etc.
Provides prognostic information but it is too general for CTO

5. J Escaned Treatment of coronary perforations Istanbul 2015
Anatomical classification of coronary
perforations in CTO PCI
• Main vessel perforation
• Distal artery wire perforation
• Collateral vessel perforation (septal or
epicardial collateral).
Complements the Ellis classification in CTO PCI

6. J Escaned Treatment of coronary perforations Istanbul 2015
Main vessel perforation
• Avoid balloon dilation if you suspect
that the guidewire is not within the
vessel architecture
• IVUS imaging can be of great help
in clarifying the size of vessel distal
to the CTO: negative remodelling
may lead to oversizing and
perforation.
• Use of IVUS facilitates safe balloon
size selection in CART / reverse
CART procedures.

7. J Escaned Treatment of coronary perforations Istanbul 2015
Distal artery with perforation
• Perforation of distal branches can
remain concealed and pass
unnoticed.
• It may be exacerbated by
concomitant use of potent
anticoagulation / antiaggregation.
• Typically associated to hydrophilic
wire use (implications for OTW
exchange)
• Treatment may include selective
embolization of coils, subcutaneous
adipose tissue or polymer.

8. J Escaned Treatment of coronary perforations Istanbul 2015
Collateral vessel perforation
• Consequences of perforation differ
in septal and epicardial vessels
• Blunt tip wires (Sion family) are
generally preferred to avoid
collateral perforation.
• Roadmapping with tip injections
may decrease its occurrence.
• The microcatheter can be used to
control bleeding and to apply suction
and collapse the collateral.
• Bilateral injections are important to
ensure complete hemostasis.

9. J Escaned Treatment of coronary perforations Istanbul 2015
Case #1 Repeat PCI in CTO

10. J Escaned Treatment of coronary perforations Istanbul 2015
Interlock™ Fibered IDC Occlusion System / Boston Scientific

11. J Escaned Treatment of coronary perforations Istanbul 2015
General measures
• Management includes 1) adequate interpretation of angiographic result,
2) sealing of perforation, 3) management of haemodynamic compromise
and 4) close follow-up of the patient.
• Ensure availability of specific devices before initiating risk cases (THM
from this case).
• Consider reversal of anticoagulation (THM form this case).
• Use contralateral vascular access to prepare specific gear to treat the
rupture (for example, graft stent), while performing hemostasis with an
inflated balloon.
• Whenever possible, perform angiography guided pericardiocenthesis
(preferred to echocardiographic guidance)

12. Case by courtesy of Rainer Zbindend MD and Franz Eberli MD
Case #2 PCI in SVD (CTO)

14. • AR2 7F guide
• Pilot 50 hydrophilic wire
• Falcon CTO 1.0x14mm balloon (monorail) and Maverick
2.0x20mm balloon (monorail)
• JL4 6F for contralateral injection (LCA)
• Total of 3 long DES implanted (Biomatrix ®)
Case #2 PCI in SVD (CTO)

18. 3h post intervention:
• Pt feels unwell
• Blood pressure is 60/40mmHg
• Rhyhtm: Sinus rhythm, 95/min
•  Emergency echo
Case #2 PCI in SVD (CTO)

20. • Pericardial drain was inserted and approximatly 300ml of
fresh blood aspirated
• After removal of intial 50ml of blood, the patient was
stable and blood pressure back to normal
• Autotransfusion via cubital iv line was started
• After approx. 30 min the bleeding seemed to stop (1-1.5
liter of autotransfusion)
Case #2 PCI in SVD (CTO)

21. • Pt became unstable within minutes, blood pressure
at 60/40mmHg
• The drain was exchanged and after aspiration of
another 50-100ml of fresh blood the patient was
stable again  drain was clogged up
• Autotransfusion was contiuned for another 40min
(ca. 50ml autotransfusion/min)
But....

27. Result:
• Flow through the PDA almost stopped after a total of 12
coils were placed into the PDA
• Covered stent could not be advanced over the PDA ostium
• Continous drainage of 40-50ml fresh blood per minute
from the peridardium

31. Emergency surgery:
• Major coagulation problems (INR , aPTT ,
Fibrinogen  (prolonged autotransfusion?)
• 2 FFP and 1 pack of Tc were transfused
• Median sternotomy
• Beating heart/off-pump
• Pericardial patch over the ruptured collateral
Case by courtesy of Rainer Zbindend MD and Franz Eberli MD
Case #2 PCI in SVD (CTO)

32. Follow-up:
• Pt for 2 days on ICU (transfusion of additional 1 FFP , 1 Tc
and 2 packed red cell concentrates)
• Recovered well
• Rehab for 3 weeks
• Pt asymptomatic
Case by courtesy of Rainer Zbindend MD and Franz Eberli MD
Case #2 PCI in SVD (CTO)

33. J Escaned Treatment of coronary perforations Istanbul 2015
General measures
• Management includes 1) adequate interpretation of angiographic result,
2) sealing of perforation, 3) management of haemodynamic compromise
and 4) close follow-up of the patient (THM from this case).
• Ensure availability of specific devices before initiating risk cases.
• Consider reversal of anticoagulation.
• Use contralateral vascular access to prepare specific gear to treat the
rupture (for example, graft stent), while performing hemostasis with an
inflated balloon.
• Whenever possible, perform angiography guided pericardiocenthesis
(preferred to echocardiographic guidance)

34. J Escaned Treatment of coronary perforations Istanbul 2015
Case #3 PCI in RCA CTO

35. J Escaned Treatment of coronary perforations Istanbul 2015
Reversal of anticoagulation & restoration of
platelet function
• May not be necessary if sealing of perforation can be adequately
performed.
• Consider reversing antocoagulation with protamine sulphate… but
beware of thrombotic complications if hardware left within the coronaries.
• Reversal of anticoagulation with LMWH, fondaparinux or bivalirudin is
not possible (preferably avoid in CTO cases).
• IIb/IIIa inhibitors should also be avoided. Abxicimab can be reversed by
platelet (6-10 units); no antidote for eptifibatide or tirofiban.
• Oral antiplatelet therapy with aspirin, clopidogrel or cilostazol should be
reinitiated in stented patients after pericardial drainage.

36. J Escaned Treatment of coronary perforations Istanbul 2015
Thank you for your attention!