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.
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.
