Complications of Percutaneous Coronary Intervention
Mauro Moscucci, MD, MBA
Advancements in technology have led to a significant increase in the safety of invasive diagnostic and therapeutic cardiovascular procedures. However, the recognition, management, and prevention of complications continue to be critical components of current practice of interventional cardiology. The objective of this chapter is to provide a visual resource that can be used for the identification and management of common and less common complications of percutaneous coronary intervention (PCI).
CORONARY ARTERY DISSECTION
Following the introduction of coronary stents, coronary artery dissection requiring emergency coronary bypass grafting has become a rare occurrence, with most series listing it at less than 0.2%.1,2 That said, it is critical to recognize this complication even in the absence of abrupt closure, as early treatment improves vessel patency and patients’ outcomes. Causes of iatrogenic coronary artery dissections include guiding catheter—induced dissection, spiral dissection following initial balloon dilatation, and stent edge dissection. The classic type “A-F” classification remains useful to describe the severity of luminal injury3 (Tables 2.1 and 2.2). Thorough angiographic and IVUS evaluation and appropriate intervention can avoid progression and maintain vessel patency (FIGURES 2.1, 2.2, 2.3, 2.4 and 2.5).
AORTIC AND GREAT VESSELS DISSECTION
In rare instances, aggressive guiding catheter manipulation or forceful contrast injection with a poorly engaged catheter can result in dissection of a sinus of Valsalva4 or of a subclavian artery. Retrograde dissection involving the sinus of Valsalva and the ascending aorta is more frequent with interventions on the right coronary artery (81% of cases) and with the use of Amplatz guiding catheter. The classification of aortic dissection is shown in Table 2.3. Prompt recognition and assessment of the extent of the dissection and hemodynamic state should guide appropriate management with either conservative, percutaneous rescue, or surgical therapy. In general, management includes ostial stenting to seal the dissection in class I and II and surgery for extensive dissections (class III) associated with hemodynamic instability (FIGURES 2.6, 2.7, 2.8 and 2.9).
TABLE 2.1 Coronary Dissection Type and Suggested Interventions | ||||||||
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TABLE 2.2 Morphologic Classification of Coronary Dissection | ||||||||||||||||
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 FIGURE 2.1 Angiographic appearance of a Type D spiral dissection, during and after contrast injection. IVUS images show the true and false lumen. A, A thin spiral dissection line can be visualized throughout the length of the vessel. B, False lumen staining becomes apparent after injection of contrast. C, IVUS demonstration of true and false lumen. It can be noticed that the IVUS catheter is located in the false lumen. Reproduced with permission from Moscucci M. Complications of Cardiovascular Procedures: Risk Factors, Management and Bailout Techniques.Philadelphia: Lippincott Williams and Wilkins; 2011. |
 FIGURE 2.2 Spiral dissection caused by aggressive manipulation of a guiding catheter. A, Diagnostic right coronary contrast injection demonstrates a severe stenosis in the mid-vessel (arrow). B, Aggressive manipulation of an Amplatz guiding catheter caused a spiral dissection that extended throughout the length of the vessel. C, The true lumen could not be wired, despite exchanging the guiding catheter for a Judkins right shape. D, The round shape in the IVUS image to the left demonstrates that the wire and catheter were in the false lumen (white arrow). In the image to the right, the true lumen (white arrow) is compressed by the false lumen. Reproduced with permission from Moscucci M. Complications of Cardiovascular Procedures: Risk Factors, Management and Bailout Techniques. Philadelphia: Lippincott Williams and Wilkins; 2011. |
 FIGURE 2.3 Guide catheter-induced coronary dissection and treatment with stent placement. A, Cranial left anterior oblique image showing the aggressive selective cannulation of the left circumflex coronary artery with an extra backup catheter. B, Occlusive dissection and contrast staining in the left circumflex in right anterior oblique. Note that the wire position was preserved throughout the case. C, Final result with complete restoration of flow after stent placement. Reproduced with permission from Moscucci M. Complications of Cardiovascular Procedures: Risk Factors, Management and Bailout Techniques. Philadelphia: Lippincott Williams and Wilkins; 2011. |
 FIGURE 2.4 Stent edge dissection with intravascular ultrasound imaging. A, Narrowed segment (white arrow) in the main left circumflex that became apparent after placement of a stent in a moderatesized second obtuse marginal branch (black arrow). B, Intravascular ultrasound demonstrated the presence of a proximal edge stent dissection (arrow) that was treated with placement of an additional stent. Reproduced with permission from Moscucci M. Complications of Cardiovascular Procedures: Risk Factors, Management and Bailout Techniques. Philadelphia: Lippincott Williams and Wilkins; 2011. |
 FIGURE 2.5 Proximal dissection of a left internal mammary artery caused by aggressive manipulation of a 0.035” guide wire (arrow). Reproduced with permission from Moscucci M. Complications of Cardiovascular Procedures: Risk Factors, Management and Bailout Techniques. Philadelphia: Lippincott Williams and Wilkins; 2011. |
TABLE 2.3 Classification of Retrograde Dissection of Sinus of Valsalva and Ascending Aorta | ||||||
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 FIGURE 2.6 Guiding catheter dissection of the right coronary ostium extending into sinus of Valsalva and the aortic root. Orthogonal views obtained with biplane angiographic equipment, showing a large dissection of the right sinus of Valsalva. The patient presented with clinical instability including hypotension and severe chest pain and was immediately referred for surgical repair of the aortic root. Reproduced with permission from Moscucci M. Complications of Cardiovascular Procedures: Risk Factors, Management and Bailout Techniques. Philadelphia: Lippincott Williams and Wilkins; 2011. |
 FIGURE 2.7 A and B, Left main dissection extending into the left coronary and noncoronary aortic cusps (arrow). Reproduced with permission from Moscucci M. Complications of Cardiovascular Procedures: Risk Factors, Management and Bailout Techniques. Philadelphia: Lippincott Williams and Wilkins; 2011. |
 FIGURE 2.8 Guiding catheter dissection of the proximal right coronary artery and sinus of Valsalva. Coronary angiography showing a dissection in the proximal right coronary artery (single arrow) extending to the right sinus of Valsalva (double arrow). The dissection developed following engagement of the right coronary artery with an Amplatz guiding catheter during PCI of a mid-right coronary artery stenosis. It was managed by stenting the proximal right coronary artery segment through a JR4 guiding catheter. |
 FIGURE 2.9 Left main dissection extending to the ascending aorta. A, Total occlusion of the left circumflex artery and of the left anterior descending artery in an 86-year-old patient presenting with NSTEMI. The left internal mammary artery graft to the LAD and the saphenous vein grafts to the obtuse marginal artery and to the PDA were patent. B-D, Following aggressive guiding catheter manipulation, there is an extensive dissection involving the left main coronary artery and the ascending aorta (white arrows). E, Deployment of a 3.5 mm × 20 mm stent in the left main coronary artery. F, Following stenting of the left main coronary artery, there is no further visualization of the aortic dissection, consistent with sealing of the dissection entry port. |
CORONARY PERFORATION
Coronary perforation is a relatively uncommon complication of percutaneous coronary interventions. It can present with a spectrum of severity ranging from an extraluminal crater without extravasation of contrast to extravasation of contrast through a >1-mm exit hole leading to pericardial tamponade, or to a coronary-cameral fistula5 (Table 2.4). While the introduction
of covered stents and of coil embolization has provided interventional cardiologist with new tools for a nonsurgical management, coronary perforation continues to be associated with high morbidity and mortality, and it is responsible for up to 20% of cases referred for emergency bypass surgery. Thus, familiarity with its early recognition and emergency management are critical components of current interventional cardiology practice6 (FIGURES 2.10, 2.11, 2.12, 2.13, 2.14, 2.15, 2.16, 2.17, 2.18 and 2.19).
of covered stents and of coil embolization has provided interventional cardiologist with new tools for a nonsurgical management, coronary perforation continues to be associated with high morbidity and mortality, and it is responsible for up to 20% of cases referred for emergency bypass surgery. Thus, familiarity with its early recognition and emergency management are critical components of current interventional cardiology practice6 (FIGURES 2.10, 2.11, 2.12, 2.13, 2.14, 2.15, 2.16, 2.17, 2.18 and 2.19).
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