Abstract
Urgent cardiothoracic surgical intervention for the management of complications of percutaneous coronary intervention is uncommon in the stent era. Nonetheless, given increasing procedural complexity, in part reflecting an aging population, an ongoing hazard for urgent surgery remains. We sought to review the incidence and outcome of urgent cardiothoracic surgery in patients undergoing PCI in a contemporary cohort at a tertiary referral centre. The incidence of cardiothoracic intervention for PCI related complications was low at 0.1% over a ten-year period, with iatrogenic coronary artery and aortic root dissection unable to successfully managed percutaneously recurrent precipitants for surgical involvement. Procedural features associated with the need for urgent surgery are noted and methods to overcome such complications discussed.
Highlights
- •
The incidence of emergency cardiothoracic surgery for complications of percutaneous coronary intervention (PCI) over a 10-year period was 0.1%.
- •
Coronary artery dissection complicating guide catheter use was the most common complication observed
- •
Complex right coronary artery interventions and use of Amplatz guide catheter increase the risk of guide catheter dissection
- •
Patients whom require emergency surgery have significant morbidity and mortality; delay in proceeding to surgery increases the mortality.
1
Introduction
While the need for urgent cardiothoracic surgery after percutaneous coronary intervention (PCI) has declined with advances in percutaneous techniques, a small proportion of patients will continue to require urgent surgical intervention. This may reflect an aging population in combination with greater procedural complexity that may predispose to complications necessitating surgical intervention.
3
Methods
We performed a retrospective observational study in a tertiary referral centre. In this study all patients who sustained a procedural complication requiring urgent cardiothoracic surgery following percutaneous coronary intervention were identified. Review of all cardiac catheterisation procedures, including primary and rescue PCI, performed during the period of October 2006 until April 2017 was performed. This cohort was then matched against those patients who underwent a cardiothoracic surgical procedure within 12 h and 24 h to determine the incidence of emergent cardiothoracic surgery after PCI. The two databases were linked using three identifiers: gender, date of birth and a unique medical record number.
Once the cohort of patients undergoing surgery as a consequence of a PCI related complication was identified, the patients’ medical records were reviewed and clinical, demographic and procedural data were recorded in a separate procedural complication registry. Relevant information including demographic data, cardiovascular risk factor profile, coronary anatomy and procedural equipment, in particular guide catheter choice, was reviewed. All cardiac catheterisation films were reviewed to determine the presence and extent of coronary and aortic calcification. Cardiothoracic procedural notes and images were reviewed to confirm the nature of any underlying complication. Inpatient length of stay and mortality were described. The time from cardiac catheterisation to surgery was calculated from the time of catheter based procedure completion to recorded time of cardiac surgery commencement. Readmission within 30 days, inpatient clinical outcomes including death and long term clinical outcomes including cardiac and all-cause mortality to determine outcome of emergent cardiothoracic surgery following PCI related complications were sourced from the Cardiac and Stroke outcomes unit.
The review was approved by the institutional ethics committee.
4
Results
Data was prospectively collected for all patients undergoing coronary angiography at our centre from October 2006 to July 2017. A total of 20,098 coronary angiograms were performed including 7713 percutaneous coronary intervention procedures. Of these 32 patients underwent emergency cardiothoracic surgery within a 24-h period, with 25 patients undergoing emergent surgery for left main stem disease. Patients referred for valvular intervention were excluded from analysis ( Fig. 1 ).
Seven (0.1%) patients with a mean age of 68 years (41–75 years) underwent PCI requiring subsequent emergency surgery within 24 h. Procedural data is outlined in Table 1 , with 6/7 cases directly attributable to coronary artery dissection complicating PCI which was not able to be satisfactorily treated with percutaneous therapy. One patient (patient number 6) underwent surgery after left main dissection occurred during diagnostic angiography which was successfully temporized with PCI. Of the 7 patients undergoing PCI, 3 underwent surgery as a consequence of right coronary artery or aortic root dissection in the context of Amplatz guide catheter use in complex right coronary artery interventions ( Fig. 2 ), with a further patient undergoing surgical removal of a retained angioplasty guide wire following entrapment between stents in a similarly complex right coronary artery lesion. Two patients required intra-aortic balloon pump insertion. The average length of stay was extended by 11 days compared to an uncomplicated PCI procedure.
| Indication/procedure | Access | Catheter | Findings | PCI | Time to surgery (minutes) | Surgical outcome | |
|---|---|---|---|---|---|---|---|
| Patient 1 Age: 75 Gender: Female | NSTEMI PCI LAD | Femoral | 6F XB 3.0 Guide | Mid LAD 90% stenosis | Balloon rupture during predilatation producing extensive dissection. Unable to advance stent which subsequently dislodged from balloon in LMCA resulting in pain and hypotension. IABP inserted. | 75 | SVG to OM and LAD |
| Patient 2 Age: 68 Gender: Male | STEMI PCI RCA | Radial | 6F JR 4 Guide | Tortuous calcified RCA with distal 100% stenosis | Following predilatation, bare metal stent (×4) implantation and postdilatation requiring use of support wire, unable to remove BMW wire at end of case. Brief period of asystole requiring temporary pacing wire insertion. | 128 | Guidewire entangled within stents – removed and SVG to distal RCA |
| Patient 3 Age: 73 Gender: Male | Chronic stable angina PCI RCA | Femoral | 6F AL 1 Guide | Tortuous calcified 80% distal RCA stenosis | Following predilatation, attempt to pass Whisper Extra support wire into distal vessel complicated by wire dissection. Unable to deliver stent. Stent dislodged requiring retrieval with gooseneck snare. Extensive RCA dissection. | 304 | SVG to PDA |
| Patient 4 Age: 62 Gender: Male | STEMI PCI RCA | Femoral | 6F AL1 Guide | Tortuous RCA with 70% proximal and 80% distal stenosis | Following predilatation during attempts to deliver distal stent, aortic root dissection noted. Stent deployed at RCA ostium and IABP inserted. | 208 | Dissection of ascending aorta with root repair and replacement with 30 mm Graft. SVG to PDA. |
| Patient 5 Age: 73 Gender: Male | Chronic stable angina Diagnostic angiography | Femoral | 6F JL4 diagnostic catheter | 60% distal LMCA stenosis. | LMCA dissection noted during diagnostic angiography; ostial lesion treated with bare metal stent insertion. | 95 | SVG to OM2 with skip to OM1. LIMA to LAD |
| Patient 6 Age: 68 Gender: Female | NSTEMI PCI LAD | Radial | 6F XB 3.5 Guide | Calcified LAD extensive disease in proximal and mid vessel. | Following predilatation, Guideliner® required for stent delivery. Dissection noted extending proximally to ostium of LMCA. Ostial LM treated. Residual dissection noted in proximal LAD – unable to pass stent due to heavy calcification. | 395 | Ascending aorta dissection repaired with 28 mm Graft. SVG to OM and SVG to LAD. Failed to wean off cardiopulmonary bypass. |
| Patient 7 Age: 41 Gender: Male | STEMI PCI RCA | Radial | 6F AL 1 Guide | Tortuous RCA with mid 95% stenosis | Catheter induced RCA dissection with antegrade progression prior to wire placement. Unable to place wire in true lumen. | 55 | SVG to distal RCA |
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
