Abstract
Coronary perforation is a rare but potentially lethal complication of percutaneous coronary intervention. Management of coronary perforations is mainly conditioned by the extension of coronary rupture and location of the perforation. Successful treatment is highly affected by the operator’s familiarity with tools and dedicated techniques to achieve prompt sealing of the disruption. We report a case of an epicardial collateral channel perforation occurred during a retrograde chronic total occlusion revascularization procedure that was promptly managed with bilateral coils embolization in the target and in the donor vessel. Based on medical literature an overview of the most helpful techniques to treat these complications is provided.
Highlights
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Coronary perforation is a rare but potentially lethal complication of percutaneous coronary intervention.
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Management of CP is mainly conditioned by the extension of coronary rupture and location of the perforation.
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Successful treatment is affected by the operator’s familiarity with tools and dedicated techniques to achieve prompt sealing of the disruption.
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We report a case of a epicardial CC perforation occurred during a retrograde CTO PCI that was promptly managed with bilateral coils embolization.
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We provided an overview of the main techniques that could be helpful in the management of CPs, according to their anatomic location.
1
Introduction
Coronary perforation (CP) is a rare but serious complication of percutaneous coronary intervention (PCI) [ ]. The incidence of CP during standard PCI is estimated at 0.1–0.84% [ ]. Although rare, CP is associated with an increased risk of adverse outcomes including tamponade, myocardial infarction, need for emergency coronary artery bypass grafting (CABG), and death [ ]. The majority of studies thus far have included rather a modest number of patients and it is unclear which preprocedural patient factors are associated independently with an increased risk of CP as well as which factors increase the risk of adverse outcomes after CP. In addition, given the improvement of equipment and therapies, the advancing age of the population and changing guidelines, PCI utilization in certain higher risk subgroups, including the elderly or those with coronary chronic total occlusions (CTOs), has been increasing [ ]. The incidence of perforation during CTO PCI is between 1.3%–13.6% [ ], but its clinical significance is variable. CPs are rarely associated with significant clinical consequences and the overall risk of cardiac tamponade is only around 0.3% [ ]. When caused by a wire, a perforation through the adventitial layer of the vessel is usually distal and point-like; conversely, when caused by a device such as a balloon, rotablator or stent, it often represents a true lateral tear of the vessel wall. CPs are traditionally classified using the Ellis classification [ ], that could be utilized to predict outcome and plan treatment. However, since current retrograde CTO PCI techniques had not been developed at the time of the Ellis classification, the algorithm does not take into consideration perforation of either septal or epicardial collaterals. With CTO interventions, classification of coronary perforations according to their anatomic location seems more relevant for treatment and outcome. Three main segments are considered: 1) main vessel (MV) perforation; 2) distal coronary perforation; 3) collateral channel (CC) perforation [ ]. Successful management of these life-threating complications depends on the operator’s knowledge of tools and dedicated techniques to achieve prompt perforation’s sealing. The management strategies range from observation to prompt intervention depending on the following aspects: severity of the perforation, presence of pericardial effusion, hemodynamic status of the patient, location of perforation, operator’s skills, equipment availability and interventional practices applied in centers. Management of large MV perforations generally requires use of the “dual catheter” technique, in which a balloon is immediately delivered through the first guide catheter (GC) to stop bleeding whereas the covered stent is then delivered through a second GC [ ]. Recently a single guide catheter technique has been described to manage large MV perforation using a covered stent, however this technique is applicable only if the balloon used for hemostasis and the covered stent can fit through a single (usually 8 Fr) guide catheter [ ]. In case of distal coronary artery or CC perforation the first step is always to stop bleeding by inflating a balloon proximal to the perforation site. If balloon inflation seals the perforation, observation and heparin reversal (after removal of equipment from the coronary artery) may be all that is needed. Sometimes, suction applied through a microcatheter may collapse the vessel and achieve hemostasis [ ]. However, in most cases definitive treatment with embolization or a covered stent is preferred to minimize the risk for late re-opening and late tamponade [ ]. Although distal or end-artery perforations can be sealed employing embolization with polyvinyl alcohol, collagen foam or intra-arterial thrombin or autologous fat tissue aspirated from the patient’s groin [ ], these strategies could be less predictable and more technically challenging, so coils delivery is the most reliable strategy to manage distal CPs. Another situation is represented by a large MV perforation during primary PCI of acute miocardial infarction (AMI) or during CTO PCI, while the vessel is still occluded. In such situation it is not possible to deploy a covered stent across the perforation and the only way to achieve a complete haemostasis is represented by prolonged balloon inflation, anticoagulation reversal and finally, in case of persistent blood extravasation, MV embolization precluding any further PCI. In summary, there are no standardized techniques to achieve prompt and effective perforation’s sealing and treatment is left to the operator’s preference and expertise. Recently, two similar single-guide, microcatheter-based techniques (also called block and delivery techniques), have been described to manage distal coronary and collateral channel perforations [ , ]. We report a case of an epicardial CC perforation occurred during a retrograde CTO PCI that was promptly managed with bilateral coils embolization using a simultaneous “block and deliver” technique in the target and in the donor vessel. Keeping this case as a focus, the purpose of this article is to provide an overview of the main techniques that could be helpful in the management of CPs, according to their anatomic location.
2
Case presentation
A 66-years-old man was admitted to our hospital with effort angina and early positive treadmil stress test. The left ventricule ejection fraction was normal with hypokinesia of the antero-lateral wall. The patient had a history of previous PCI of both proximal left anterior descending artery (LAD) and proximal left circumflex artery. During hospitalization a diagnostic coronary angiography showed mid LAD CTO, filled by epicardial CC from an acute marginal (AM) branch of the right coronary artery (RCA). We scheduled an LAD CTO PCI using bilateral femoral artery access with two 45 cm long 7 Fr sheaths. The left main was engaged with an XB 3.5 SH 7 Fr guiding catheter (GC), while the RCA was engaged with an AL 1 SH 7 Fr GC. After a failed antegrade approach due to the progression of the wire in the subintimal space, we switched to a retrograde approach using as interventional collateral the epicardial collateral channel originating from distal AM branch ( Fig. 1 ). We advanced a Finecross microcatheter (Terumo Corporation, Tokyo, Japan) over a workhorse guidewire through the acute marginal branch, then we used a Sion Blue wire (Asahi Intecc, Nagoya, Japan), with a 90° bend 1 mm from the tip, to negotiate the epicardial channel. After successful epicardial CC crossing with the Sion Blue guidewire, the Finecross was advanced into the LAD true lumen close to the distal cap, then a GAIA 2nd wire (Asahi Intecc, Nagoya, Japan) was able to cross the CTO body achieving a retrograde true-to true lumen tracking. After advancing the retrograde guidewire and the Finecross microcatheter into the antegrade GC, the short retrograde wire used to cross the occlusion was removed, and exchanged for a 330 cm long RG3 wire (Asahi Intecc, Nagoya, Japan), advanced through the opposite hemostatic valve converting the recanalization of the LAD to an antegrade fashion. Once stenting was completed, before removing the retrograde gear we performed a contrast injection from the retrograde GC without any sign of injury of the collateral vessel ( Fig. 2 ). Finally the RG3 guidewire was removed after re-advancing the Finecross microcatheter over the guidewire to minimize the risk for injury of these tortuous epicardial collaterals. Despite these precautions a final angiography showed a big perforation of the epicardial collateral channel, that was filled from both sides of the perforation ( Fig. 3 ). We performed the “block and deliver” technique in both vessels (LAD and RCA) delivering one detachable coil for each side, achieving a fast, effective and complete hemostasis. In detail we immediately performed a simultaneous balloon occlusion of both vessels (distal LAD and AM branch of the RCA) ( Fig. 4 ) without reversal of heparinization, then we advance a Finecross microcatheter over a second guidewire into the distal LAD. Temporary balloon deflation allowed the Finecross to be advanced close to the epicardial collateral channel take-off. Leaving the occlusion balloon inflated into the distal LAD we were able to negotiate through the “trapped” microcatheter the epicardial channel with a Sion Blue guidewire ( Fig. 5 A ), then we advanced the Finecross microcatheter into the injured CC close to the perforation. After removing the Sion Blue guidewire we performed a tip injection that confirmed persistent blood extravasation ( Fig. 5 B), so one 0.010”Axium detachable coil (Ev3 Neurovascular, USA) was successfully delivered through the trapped microcatheter, achieving an antegrade hemostasis ( Fig. 5 C). Finally we repeated the same maneuver into the AM branch of the RCA ( Fig. 6 ), delivering another single 0.010” Axium detachable coil through the “trapped” microcatheter ( Fig. 7 ), achieving a complete sealing from both sides of the perforation ( Fig. 8 ). The bilateral coils embolization procedure was very fast and effective and an echocardiographic examination performed at the end of the procedure didn’t show any sign of pericardial extravasation. The patient was discharged two days after the procedure.
3
Discussion
As recently described the “block and deliver” technique consists in simultaneous delivery of a balloon and a microcatheter through a single ≥6-French GC [ , ], obviating the need for “dual guide” catheter technique. The most important benefit that may derive from this technique is the possibility to accurately assess sealing of the perforation before and after release of microcoils by tip injections from the microcatheter, without the need to repeatedly deflate the proximal occluding balloon. However adequate expertise in coil deployment is mandatory and detachable coils are preferable because optimal positioning can be confirmed before releasing them. We described a case of a epicardial CC perforation, occurred during a retrograde CTO PCI, in which the “block and deliver” technique was simultaneously performed in LAD and RCA to achieve rapid, safe and effective embolization from both side of the perforation [ ]. However, in case of CC perforation during retrograde CTO PCI, embolization from both sides of perforation may not be feasible if the occlusion cannot and/or has not been recanalized. Although in most of such cases selective embolization of the CC proximal to the perforation is sufficient to cause hemostasis (after proximal coil implantation, retrograde intra-channel pressure from an occluded vessel is low), bilateral angiography is always mandatory to rule out retrograde bleeding, which might eventually constitute an indication for cardiac surgery.
4
General principles of coronary artery perforation management according to their anatomic location
As a general rule, reversal of anticoagulation should in most cases not be performed until after removal of interventional equipment, because reversing the heparin carries the risk of guide and/or target vessel thrombosis.
4.1
Main vessel perforation
This complication can occur after implantation of an oversized stent (stent/vessel diameter ratio >1) or after high-pressure balloon inflation. Another instance is that of inadvertent extraluminal progression of the wire during lesion crossing, followed by advancement of a balloon or microcatheter towards the pericardial space. A limited wire perforation (diameter from 0.09 to 0.014″) is very unlikely to cause significant blood loss into the pericardial space or tamponade, while the risk is exponentially increased by passage of a device both because of the larger size and also for a tearing effect on the vessel walls. Should this occur, immediate balloon inflation upstream is mandatory to block forward flow; if extravasation persists in spite of prolonged balloon inflations, the next step is to place a covered stent. If the wire is distal to the lesion and to the perforation site, a covered stent should be placed at the level of the perforation. Depending on the size of the guide catheter being used and the size of the covered stent, delivery of the covered stent could be achieved using a single guide catheter (also called block and deliver technique) [ ] or two guide catheters (dual guide catheter, also called “ping pong” guide catheter, or “dueling” guide catheter technique) [ ]. The goals of both techniques is to minimize bleeding into the pericardium while preparing for covered stent delivery and deployment. Otherwise, if severe MV perforation occurs during a CTO PCI while the vessel is still occluded, it is not always possible to deploy a covered stent across the perforation. The only way to maintain complete haemostasis is by prolonged inflation of an occluding balloon and, with persistent blood extravasation, embolization of the MV itself precluding any further attempt at vessel recanalization and PCI. One anecdotal case of a successful CTO PCI during a severe MV perforation while the main vessel was still occluded has been described [ ]. As suggested by the authors this strategy should be considered if proceeding with a recanalization attempt seems reasonable, with a good chance of a safe procedural and clinical success by both recanalization of the occluded artery and sealing of the breach with deployment of a covered stent. However, the most important aspect to consider is the hemodynamic stability of the patient, the lack of progressive pericardial effusion and the characteristics of the CTO associated with a higher success rate (for example short length <20 mm and straight course). The attempt should be brief, must absolutely avoid causing other perforations; and if unsuccessful may be followed by complete MV embolization and closure with coils (or emergency surgery as required). The main limitation of this application of the “block and deliver” technique in this setting is that successful recanalization of the chronically total occluded MV is not always predictable and success is contingent on the ability to reach the distal true lumen through the occlusion, oftentimes quite difficult and time–consuming. If a covered stent cannot be delivered to the perforation site, prolonged balloon inflation could lead to hemostasis. Usually heparin is not reversed, until after hemostasis is achieved and equipment is removed from the coronary artery. If pericardial bleeding continues despite prolonged balloon inflations, emergency cardiac surgery may be required.
4.2
Distal vessel perforation
Distal vessel perforation is usually caused by inadvertent excessive advancement of a wire into the distal coronary bed. Stiff, tapered or plastic jacket guidewires are at highest risk. Since seepage of blood into the pericardium may be very slow and not perceived during PCI, cardiac tamponade may occur even a few hours after completion of the procedure [ ]. It is then vitally important to strictly monitor the patient in the hours following the procedure of recanalization, with sequential hemodynamic parameters (blood pressure, pulse rate, etc.), but also with a repeat echocardiogram whenever in doubt of such a complication [ ]. Intraprocedural treatment usually consists of a prolonged balloon inflation at the site of perforation; alternatively, a microcatheter can be advanced to the site and aspiration performed to try and collapse the distal vessel walls to obtain complete hemostasis [ ] and finally, if still unsuccessful, distal embolization [ ]. Coils embolization is the most common treatment for distal vessel perforation; in rare cases fat, thrombin, thrombus, microparticles, portion of a guidewire, or other materials are used for embolization, although this strategy could be less predictable and more technically challenging. Although even in case of distal CPs the most used technique is the “dual guide” technique, embolization can be achieved through a “single guide” (block and deliver) technique, as recently described by Tarar et al. [ ] and Garbo et al. [ ]. When the perforated branch is too small or too angulated to allow wiring and delivery of a microcatheter, an alternative treatment strategy is implantation of a covered stent across the ostium of the perforated branch. In rare cases in which neither embolization nor covered stent delivery are feasible prolonged balloon inflations may lead to hemostasis, otherwise cardiac surgery may be required.
4.3
Collateral vessel perforation
Perforation or rupture of an epicardial collateral may happen during a CTO PCI retrograde procedure and it is a very serious complication, that can rapidly lead to cardiac tamponade and may be quite difficult to treat. Conversely, perforation of a septal branch is unlikely to be associated with severe clinical consequences. History of previous CABG is not really “protective” against the risk of tamponade, because sometimes bleeding may cause a loculated hematoma that compresses various cardiac chambers and cause hypotension, shock or death. Such hematomas may require drainage under computed tomography guidance or surgical evacuation. Perforation of a collateral vessel may occur during advancement of the guidewire but also while navigating various other devices, so extreme care must be kept to monitor the position of the wire even when not directly handled but only used as support. Treatment of these perforations could be different, according to their location (septal or epicardial).
4.3.1
Perforation of a septal collateral channel
Septal perforation is mostly a rare and self-limited event, with unlikely critical clinical consequences, even though large septal hematomas and even cardiac tamponade secondary to septal rupture are reported in the literature [ ]. It is important however to clearly characterize the anatomic path of a septal branch, as sometimes they may in part run an epicardic course. Furthermore, a septal perforation most often drains in one of the cardiac chambers, without significant hemodynamic impact [ ] Advancement of a microcatheter and creation of a vacuum with aspiration from a syringe often leads to collapse of the walls of the involved septal branch with resolution of the problem [ ]. If tamponade occurs, the perforated collateral may need to be coiled.
4.3.2
Perforation of an epicardial collateral channel
Epicardial perforation or rupture is a much more dangerous complication and can rapidly lead to pericardial tamponade and hemodynamic collapse. This is why an epicardial approach should be attempted only by expert operators in CTO and retrograde interventions, and as a last resort. Should rupture of an epicardial collateral occur, immediate balloon inflation and negative aspiration from the microcatheter, after wedging the tip to stop the bleeding, must be tried and implemented at once, as described [ ]. If still unsuccessful, distal embolization with coils can also be tried, even though ideally coil embolization should be performed at both ends of the collateral, since blood flow is from both directions [ ]. This maneuver obviously cannot be attempted if the CTO has not been recanalized yet. However, selective retrograde coil embolization could still be enough for adequate hemostasis, since distal perfusion pressures beyond an occlusion are usually very low. Bilateral angiography should always still be performed to rule out the possibility of significant bidirectional blood supply that might lead to immediate emergency surgical intervention.
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