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A Practical Approach to the Management of Complications During Percutaneous Coronary Intervention by Dr. Vaibhav Yawalkar MD, DM Cardiology

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A Practical Approach to the Management of Complications During Percutaneous Coronary Intervention by Dr. Vaibhav Yawalkar MD, DM Cardiology

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A Practical Approach to the Management of Complications During Percutaneous Coronary Intervention by Dr. Vaibhav Yawalkar MD, DM Cardiology

  1. 1. Dr. Vaibhav Yawalkar MD, DM Cardiology Francesco Giannini, MD et. al. JACC , September 24, 2018
  2. 2. 1.Coronary Perforation 2.Abrupt vessel closure 3.Device Embolization 4.Longitudinal Stent Deformation 5.Rotational atherectomy burr entrapment
  3. 3. Coronary Perforation Ellis Classification of Coronary Perforation
  4. 4. Incidence 0.5% 13-fold increase of in-hospital major adverse events and a 5- fold increase of 30-day mortality Most commonly caused by balloon or stent mismatch, particularly when balloon-artery ratio is >1.2:1 or when semi- compliant balloons are inflated at very high pressure Can occasionally occur with appropriately sized catheter in the context of extensive dissection or lack of vessel wall integrity In the presence of arterial calcification Inadvertent coronary wire tip migration
  5. 5. Other Factors Use of atherectomy devices (e.g., excimer laser or rotational atherectomy) Cutting balloons Intervention on a chronic total occlusion (CTO) Advanced age, female sex, and previous coronary artery bypass grafting (CABG) Coronary Perforation
  6. 6. Sudden onset of acute and sharp chest pain during balloon inflation or stent deployment should always raise the suspicion of coronary perforation Balloons should remain in the guiding catheter and at the lesion site until further angiography has been performed to confirm (or exclude) the diagnosis Consideration for reversal of anticoagulation Approach:
  7. 7. UFH may be neutralized with intravenous administration of protamine (1 mg IV for each 100 units of UFH) to achieve an activated clotting time of <150 Sec However, this decision should be balanced against the potential subsequent risk of acute thrombosis of a stent that has just been deployed & other hardware still in vasculature. If bivalirudin has been administered, infusion of fresh frozen plasma should be considered. Relatively short half-life of bivalirudin is advantageous here and may facilitate a more rapid hemostasis.
  8. 8. Same balloon responsible for perforation should immediately be positioned at the perforation site even before pericardiocentesis, as a temporizing measure to achieve immediate hemostasis. Inflate balloon at lowest possible pressure to promote hemostasis with contrast injection at regular intervals to assess spillage from perforation Usually inflations to 2 to 4 atm for approximately 5 to 10 min are sufficient. In case of incomplete sealing, the balloon should be placed in the correct position and inflated at higher pressure.
  9. 9. If the perforation involves left main artery, a perfusion balloon or a covered stent should be considered as first-line therapy. Once the vessel is occluded by the balloon, the patient’s hemodynamic may normalize Aggressive treatment with intravenous fluids, atropine, vasopressors, and occasionally mechanical circulatory support, may be required if hypotension develops. Plan Immediate echocardiography, and when a large pericardial effusion is associated with tamponade physiology, emergent pericardiocentesis is indicated. Aspirated blood should be immediately reinfused into a vein to promote hemodynamic stability
  10. 10. Ellis grade I perforations : Occasionally resolve without intervention or can be treated with reversal of anticoagulation or balloon inflation at or proximal to the target vessel segment Ellis grades II to III : Often associated with persistent extravasation despite prolonged balloon inflations. Other measures: • Local delivery of subcutaneous fat • Use of thrombin, occlusive coils, beads • Implantation of polytetrafluoroethylene (PTFE) stents. • Emergency cardiac surgery may be required and cardiac surgeons should be notified immediately.
  11. 11. Single guiding catheter strategy: This technique consists of the rapid positioning of the covered stent immediately after deflation and retrieval of the balloon responsible for the perforation. PTFE covered stents are bulky compared with current- generation drug-eluting stents, and their delivery into tortuous vessels can be challenging. Most guide catheters cannot accommodate both an angioplasty balloon and a PTFE-covered stent graft at the same time Therefore, there should be a low threshold to use a separate guide catheter (“ping-pong” guiding catheter technique) to facilitate PTFE-covered stent delivery while maintaining hemodynamic stability
  12. 12. Separate guiding catheter strategy: This strategy involves the positioning of a wire from the second guide catheter into the coronary vessel, with the previous angioplasty balloon being momentarily deflated to allow distal passage of the second guidewire. The PTFE covered stent is then quickly advanced across the perforation and is deployed following removal of the angioplasty balloon Side-branch vessels near the perforation site may be excluded by the PTFE-covered stent, and this may result in periprocedural myocardial infarction.
  13. 13. Intravascular ultrasound (IVUS) should also be used to verify adequate covered-stent expansion as • PTFE dual-layer stents deployment requires aggressive post - dilatation to > 20 atm • Higher rates of restenosis associated with the use of these double layer stents. In some circumstances (more frequently in right coronary artery), very deep intubation of the guiding catheter should be considered, as this maneuver gives the double advantage of providing prompt hemostasis and favoring the delivery of a covered stent without the need of a second guiding catheter.
  14. 14. Perforation due to inadvertent distal migration of guidewires (most commonly hydrophilic wires), results in tip-related perforation. Many of these perforations are small and self-limiting and can be managed with prolonged balloon occlusion proximally to the site of injury. However, when extravasation persists despite these measures, definitive sealing of the perforation site can be achieved with the delivery of • Subcutaneous fat • Use of thrombin • Occlusive coils or beads These items can be selectively injected into the distal target with microcatheter, accepting a likely resultant localized MI.
  15. 15. If these interventions are unsuccessful, the vessel can be excluded with a covered stent placed across its origin in main vessel. Perforation with Feeding collaterals: Vessels receiving only anterograde or retrograde collateral flow should be managed with microsphere or beads, endovascular coils, local thrombin injection, subcutaneous fat embolization, or PTFE-covered stent deployment of the donor branches to exclude the perforated vessel. Perforations of vessels receiving both anterograde and retrograde collaterals should be treated by intervention on both anterograde- and retrograde-donor vessels to exclude the affected branch.
  16. 16. 1 2 3 4
  17. 17. 1.Coronary Perforation 3.Device Embolization 4.Longitudinal Stent Deformation 5.Rotational atherectomy burr entrapment
  18. 18. Abrupt Vessel Closure Most common major complication during PCI Decrease of its incidence from 3% in the plain old balloon angioplasty era to approximately 0.3%. • Dissection • Intracoronary thrombus formation • Native thrombus (or atheroma) embolization • Air injection • Spasm Chest pain, electrocardiographic changes, hypotension, or arrhythmias can be manifestations of acute ischemia associated with AVC.
  19. 19. Ensure the intraluminal position of the coronary guidewire and, if in doubt, an over-the-wire balloon catheter or microcatheter should be advanced distal into the target vessel to allow minimal contrast media injection and confirm wire position. Alternatively, to avoid potential dissection propagation due to contrast injection when the guidewire is located in the subintimal space, IVUS can be used to confirm wire position. Approach:
  20. 20. If intraluminal guidewire position is confirmed, the most likely mechanism underlying AVC is dissection or intraluminal thrombus. In these cases, a series of brief balloon inflations may be able to restore antegrade flow and reveal the presence of thrombus or dissection, this is typically followed by stenting of the dissection with or without thrombus aspiration. If the balloon is not advancing or recoiling more proximally, it indicates partial subintimal guidewire passage. It is advisable not to attempt subintimal revascularization while risking extensive dissection or perforation. Instead, the guidewire should be left in place and an alternative passage with a second guidewire should be sought
  21. 21. Control of anticoagulation is of paramount importance when AVC due to intracoronary thrombus formation is suspected. Activated clotting time should be measured at intervals of 30 min to ensure appropriate heparin levels. Identify the potential risk of heparin resistance, which could represent the underlying mechanism of AVC Administration of glycoprotein (GP) IIb/IIIa antagonists or direct thrombin inhibitors such as bivalirudin may be considered. Both intracoronary and intravenous administration of GP IIb/IIIa antagonists can be helpful.
  22. 22. If there is persistence of AVC, intravascular imaging should be considered to define the underlying pathology. In the presence of distal coronary embolization, thrombus aspiration or compression against the coronary artery wall should be considered. When AVC is caused by inadvertent air injection, immediate aspiration is crucial. This can be combined with administration of inotropic agents and implementation of left ventricular support in the presence of hemodynamic compromise. A different strategy consists of air bubble breakdown with the aid of a guidewire or a balloon. Concomitantly, 100% oxygen should be provided to the patient to facilitate the absorption of the embolized air.
  23. 23. Guide catheter dissection of a coronary ostium or a segment proximal to the target lesion may cause poor inflow and may be easily overlooked. Dampening or ventricularization of the pressure tracings, electrocardiography changes, or severe ischemic pain requires exclusion of ostial dissection due to guide catheter. In these situations, contrast injection should be avoided or at least minimized, and the operator should proceed to immediate ostial stenting to avoid further distal propagation of the dissection. Intravascular imaging with IVUS in this instance may be helpful to confirm the diagnosis.
  24. 24. In cases of persistent AVC, depending on the location of the occlusion, the patient’s clinical conditions, and the assessment of risks and benefits, emergency CABG may be considered. Extreme vagal reaction or sustained vasospasm may also cause AVC, and in such cases, antegrade coronary blood flow can be restored by atropine, intravenous fluid boluses, and administration of vasopressors (vagal reaction) or vasodilators (vasospasm).
  25. 25. Coronary no-reflow phenomenon Consists of the failure to reperfuse myocardium after the opening of a previously occluded or stenosed epicardial coronary artery. It is important to immediately differentiate AVC caused by dissection from no reflow, because placement of a stent in a vessel with no reflow may exacerbate the problem. The cause is likely multifactorial due to a combination of endothelial damage, platelet and fibrin embolization, vasospasm, and extracellular or intracellular tissue edema, ultimately leading to neutrophil plugs and platelet infiltration of myocardial tissue, microcirculation injury, and in the end, AVC.
  26. 26. Coronary no reflow can typically occur during primary PCI and complex lesion intervention involving treatment of venous grafts or rotational atherectomy. It has also been described in the context of NSTEMI or elective PCI The no-reflow phenomenon can be prevented or treated with diligent use of distal embolic protection devices; distal intracoronary or intravenous medications such as adenosine, nicorandil, nitroprusside, nicardipine, verapamil and epinephrine; and utilizing a microcatheter or a dual lumen catheter. Abciximab has a limited role to treat no reflow unless a clear thrombus is the cause
  27. 27. Abrupt Vessel Closure
  28. 28. Abrupt Vessel Closure
  29. 29. 1.Coronary Perforation 2.Abrupt vessel closure 4.Longitudinal Stent Deformation 5.Rotational atherectomy burr entrapment
  30. 30. Device Embolization Rare PCI complication, and is the result of the “loss” of a device (e.g., stent, guidewire, or catheter fragments; misplaced intravascular coils in the coronary arteries). Stents are the most commonly embolized devices, with an incidence of approximately 0.32%. Dislodgement of a stent may result in systemic or intracoronary embolization, may cause cerebrovascular events, high risk of coronary thrombosis and subsequent MI. Extreme tortuosity, angulation, and calcification increase the risk of stent embolization by dislodgement of the stent from the delivery balloon.
  31. 31. When unexpected difficulties in advancing a stent are encountered, the stent should be gently retracted back into the guide catheter (at an early stage before stent deformation), and removed. Then the lesion should be predilated (if was not done before) or further predilated (in addition to prior predilation). Stents may also be “lost” if the distal tip engages the lesion and remains embedded when the balloon is retracted for repositioning. Occasionally, stents may be caught by the edge of the guide catheter, with subsequent dislodgment from the balloon platform on withdrawal.
  32. 32. • Use of gooseneck snares • Additional guidewires • Guiding extension catheters If the stent remains on the wire, it is often possible to advance a small balloon beyond the stent, inflate it, and retrieve the stent by “dragging” the balloon back. Pass a second wire alongside the embolized stent through a stent strut, twist the wires together, and retract the stent. If attempts for retrieval are unsuccessful, it may be necessary to consider stent crushing to the arterial wall with balloon inflation or deployment of an additional stent alongside the embolized one, although this is associated with an elevated risk of periprocedural MI, death, and referral for CABG. Approach:
  33. 33. In large coronary arteries and difficult access sites, surgical removal should be considered. When the embolized item is a small guidewire, consider leaving the wire in the coronary artery because, there are no reports describing vessel occlusion caused by a retained guidewire segment. However, wire unraveling should be excluded (e.g., by IVUS) before leaving the wire in place, as an unraveled guidewire may form a nidus for thrombus formation. In certain instances depending on the position of the retained fragment, consider stenting the segment to prevent late distal migration, which could lead to perforation and tamponade.
  34. 34. 1.Coronary Perforation 2.Abrupt vessel closure 3.Device Embolization 5.Rotational atherectomy burr entrapment
  35. 35. Longitudinal Stent Deformation Defined as distortion or shortening of a stent along its longitudinal axis New-generation cobalt-chromium or platinum chromium stents with thinner struts & with similar radial strength and radiopacity are characterized by better trackability, pushability, and deliverability. However, the reduction of the number of fixed links between cells and the alteration of their geometry reduce their longitudinal strength, leading to an increased risk of longitudinal stent deformation. Lesion calcification, vessel tortuosity, lesion length ≥ 28 mm, ostial disease, and bifurcation disease represent the most common adverse angiographic features for LSD occurrence
  36. 36. LSD can be associated with stent strut protrusion into the lumen and extensive strut mal-apposition, which can then result in flow disruption and increased risk of future stent thrombosis. During PCI for ostial lesions involving deep intubation with guiding catheters or during PCI with extension systems through already stented segments. Deliberate under-expansion of the proximal portion of a very-long stent in a tapered vessel. Longitudinal deformation of a drug-eluting stent may result in uneven drug delivery, thereby increasing the risk of in-stent restenosis.
  37. 37. When LSD is suspected, radiographic assessment of the stented segment, preferably with StentBoost (Philips, Andover, Massachusetts) or an equivalent image-enhancement program, should be carried out. After confirming appropriate wire positioning, a small compliant balloon should be used in the first instance, followed by a high- pressure noncompliant balloon aiming to ensure adequate expansion of the deformed stent struts and their apposition to the coronary arterial wall. If an insufficient angiographic and IVUS result is obtained, implantation of a second stent may be necessary. The use of IVUS or optical coherence tomography is strongly encouraged, only after LSD has been treated to avoid further potential deformation.
  38. 38. 1.Coronary Perforation 2.Abrupt vessel closure 3.Device Embolization 4.Longitudinal Stent Deformation
  39. 39. Rotational atherectomy burr entrapment Occurs rarely, with a reported incidence of 0.4%. Entrapment consists of burr embedment through a severe stenosis, preventing both further burr advancement and retrieval (especially in the presence of tortuosity or concomitant coronary spasm). Burr entrapment can be avoided by a gentle pecking motion and short rotablation runs (< 15 sec).
  40. 40. When entrapment occurs, the most practical method to retrieve the burr is pulling the rotational system back manually. In some cases, the stuck burr can be withdrawal successfully by manual traction with on-Dynaglide (Boston Scientific, Marlborough, Massachusetts) or off-Dynaglide rotation. Excessively aggressive retrieval maneuvers may lead to vessel perforation or burr shaft fracture. Approach:
  41. 41. If simple manual traction fails, obtain a separate vascular access. A second guiding catheter can be used to allow advancement of a guide wire beyond the entrapped burr. Subsequent balloon dilation of the lesion along the entrapped burr should facilitate its retrieval
  42. 42. Partial Rotablator (Boston Scientific) disassembly and the use of a percutaneous snare : After disassembling the Rotablator apparatus to expose the burr shaft, a percutaneous snare is advanced just proximal to the burr to provide direct traction on the burr during its withdrawal. An additional alternative strategy involves the use of a GuideLiner catheter. When all percutaneous measures have failed, emergency cardiac surgery is indicated.
  43. 43. Take Home Message Despite recent advances, periprocedural complications still occur and can, in some cases, lead to severe hemodynamic compromise or even death. An in-depth knowledge of potential complications and a structured approach to their management is essential to the interventional cardiologist to ensure prevention and optimize clinical outcomes when complications occur. No matter how experienced the interventionist, complications will teach humility and be a source of continuing education throughout his or her career.

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