Anastasios D. Barmpas, MD Cardiologist University Cardiology Dpt Medical School, Democritus University of Thrace, Alexandroupolis, Greece

Transcription

1 An iatrogenic Ellis type III coronary perforation, in which the ping - pong guide catheter technique with mother and child guide catheter extension technique were successfully utilized to solve the problem. Anastasios D. Barmpas, MD Cardiologist University Cardiology Dpt Medical School, Democritus University of Thrace, Alexandroupolis, Greece

2 Disclosures None to be declared

3 Case Presentation A 58-year-old woman with a history of diabetes mellitus, dyslipidemia, and hypertension was referred for cardiac catheterization due to crescendo angina pectoris. A myocardial scintigraphy study (SPECT) showed a large reversible anterior wall perfusion defect that indicated LAD ischemia.

4 Case Presentation Physical examination: unremarkable Chest X-ray: normal Electrocardiogram(ECG): anterior T wave changes Transthoracic echo: demonstrated mild hypokinesia of the anterior wall with overall preservation of global left ventricular ejection fraction Routine laboratory evaluation: unrevealing Past medical history: disease-free Medication: Olmesartan Medoxomil/HCT, Rosuvastatin, Gliclazide, vildagliptin

5 Case Presentation Vitals signs at admission time: HR 75 beats/min, BP 120/80 mmhg Pre procedure medications: mg Ticagrelor p.o mg Aspirin p.o U Heparin i.v.

6 Baseline Angiography Access: right radial artery Sheath: 6F GlideSheath Terumo with outer diameter 5F Diagnostic catheter: 5F Tiger 4,0 Left coronary angiogram showing the severe proximal-lad lesion and the distal LAD lesion

7 Τreatment of proximal LAD Lesion Predilation of proximal LAD with 3 x 25 mm compliant balloon (14 Atm) Positioning of a 3,5 x 28 mm DE Stent(14 Atm) Postdilation with a 4 x 25 mm NC Balloon after Stent Deployment(18 Atm) Angiographic result in Prox. LAD Lesion

8 Treatment of distal LAD Lesion Predilation of the distal LAD with a 2,25 x 20 mm compliant balloon at peripheral and proximal lesion correspondingly (14 Atm) Stent positioning and deployment of a 2,5 x 38 mm DE Stent at distal LAD (16 Atm)

9 Post-stenting angiographic result

10 IVUS showed that the distal LAD Stent was under-expanded and malapposed IVUS showed that the distal LAD stent was under-expanded and malapposed, as shown in the picture At IVUS image which is set out, you indicatively see that from 5 o clock to 8 o clock position there is a large atheromatous load outside the stent. And you see a plaque which is, indeed, of mixed echogenicity, that is to say it has a calcareous element which gives this acoustic shadow behind. So, from IVUS we found that the Minimum Stent Area is under 5 mm 2 and we decided to proceed to postdilatation using a NC Balloon 2,75 mm which we believe, according to the measurements we made with IVUS, was the right choice. Based on the multiple measurements of IVUS, the reference vessel diameter was 3 mm and knowing that the intracoronary ultrasound overestimates the diameter from 0.25 to 0.5 mm in comparison to QCA we chose a ΝC Balloon 2,75 mm.

11 Postdilatation of distal LAD Stent Postdilatation of distal LAD stent with a 2,75 x 26 mm Non- compliant balloon (18 Atm)

12 Iatrogenic Perforation Type III of distal LAD According to our opinion, what happened is not due to a wrong choice of the balloon but unfortunately was something unpredictable since there was a calcium chunk, which possibly acted as splinter and caused the vessel perforation when high pressure dilatation was performed.

13 Prolonged balloon Inflation *ACT 240: No Reversal of Anticoagulation

14 Pericardiocentesis 500 ml blood drained

15 Persistent extravasation in spite of prolonged balloon inflation for 20 Μinutes

16 Insertion of a second Guide Catheter for covered stent delivery

17 The Ping-Pong Technique Reference Treatment with the Double Guiding Catheter Technique for Type III Coronary Perforation Rev bras Cardiol Invasiva 2013: 21:401-5 vol.21 Αdvantages of the Ping-Pong Technique Second Guide Catheter minimizes duration of extravasation and subsequently the possibility of cardiac tamponade. The guide wire entrapment through the dilated balloon of the first catheter provides better support for covered stent delivery specifically in spiral or calcified segments of the vessel or through already existent stents, like a distal anchoring technique.

18 Delivery of a covered stent with the Ping-Pong technique and a guide catheter extension 1 Catheter * 2 Catheter ** Guide Catheter Extension (7 Fr. Guideliner V2) Covered Stent (PK Papyrus 2,5 mm x 20 mm (13 Atm)

19 Delivery of a covered stent with the Ping-Pong technique and a guide catheter extension Key Message Guideliner improves back up support for covered stent delivery through previous implanted stent

20 Final angiographic result

21 Follow-up A contrast echocardiography was immediately performed for the exclusion of an active extravasation into the pericardium. A small pericardial effusion was found without active extravasation. Follow-up of the patient at the Intermediate care station for 48 hours the patient had no further complications. A myocardial scintigraphy study was carried out 6 months after the incident. There were no signs of ischemia.

22 Ellis Classification of Coronary Perforation Ellis Classification of coronary Perforation Type I Type II Type III *Type III cavity spilling (CS) *Sometimes referred to as Type IV Extraluminal crater without extravasation Pericardial or myocardial blush without contrast jet extravasation Extravasation through frank (>1 mm) perforation Perforation into an anatomic cavity, chamber, coronary sinus, etc. Harries I et al,eurointervention, 2014 Sep;10(5):646-7 Ellis et al,circulation,1994;90;

23 Anatomical classification of perforations Anatomically, perforation is categorized as Large Vessel Perforation - usually more profound with greater likehood of significant sequelae Distal Wire Perforation - There the aetiology is the guide wire (WIRE EXIT) and the clinical course is frequently benign Collateral perforation - occur in CTO PCI - Epicardial collateral Treatment includes both sides of the perforation (donor and recipient vessel)

24 Mechanism of Coronary Perforation Device Total Class II Class III Guidewire Stent Cutting balloon Post-dilatation Predilatation Late Hendry et al Eurointervention 2012 May 15;8(1);79-86

25 Several factors can be associated with Coronary Artery Perforation Risk Factors: Clinical Complex lesions Age Female gender Chronic total occlusion Presence of coronary calcification Hypertension Acute coronary syndrome Heart failure Procedural Atheroablative devices Cutting balloons Hydrophilic guidewire Stiff guidewire Use of IVUS Oversized device Femoral approach Harries I, Eurointervention 2014

26 Type 1 Perforation Management Watchful waiting

27 Type 2 Perforation Management Hydrophilic / CTO wires Distal perforation Embolisation: coils thrombin gelfoam / microshpheres negative pressure suction via microcatheter blood clot subcutaneous fat

28 Type 3 Perforation Management Prolonged balloon inflation (tolerated) Cardiac Tamponade - Pericardiocentesis Covered stent / 2 nd guiding catheter Reverse anticoagulation (only if ACT is greater than it should be) Surgery

29 Treatment Algorithmus of Grade III Coronary Perforations Hemodynamically unstable? Yes Grade 3 coronary perforation Prolonged balloon inflation Heparin or Gpllbllla administered? Pericardiocentesis, cardiopulmonary resuscitation +/- IABP as necessary Covered stent implantation Intolerance to prolonged balloon inflation Yes Evidence of continued contrast extravasation despite prolonged balloon inflation or intolerance to prolonged balloon inflation? Evidence of continued contrast extravasation? No Yes Heparin reversal +/- platelet transfusion as necessary Distal coronary perforation or covered stent undeliverable Prolonged balloon inflation with IABP support Coil embolization, if feasible Surgical repair of perforation +/- CABG Yes Postdilatation of covered stent Further covered stent implantation Prolonged balloon inflation +/- IABP support Coil embolization, if feasible Surgical repair of perforation +/- CABG No No further treatment No further treatment Al-Lamee R et all, JACC Cardiovasc Interv Jan;4(1):87-95

30 Covered Stents available in Europe GRAFTMASTER BeGraft PK Papyrus Aneugraft Dx Manufacturer Abbot Vascular Bentley Innomed Biotronik ITGI Medical Graft material epfte eptfe Electrospun polyurethane Processed equine pericardium Stent material/design Guide catheter compatibility Stainless steel (316L) Sandwich design 6 Fr ( 4.00 mm) 7 Fr (4.5 and 4.8 mm) Cobalt-chromium (L-605) Single layer CoCr (L-605) with amorphous silicon carbide coating Single layer 5 Fr 5 Fr (stents <4.0mm) 6 Fr (stents 4.0mm) Stainless steel (316L) Single layer Crimped profile mm mm mm mm Stent diameter (mm) Stent length (mm) Fr Nominal implantation pressure 15 atm 11 atm ( mm) 10 atm ( mm) 8 atm ( mm) 7 atm ( mm) 5 atm* Information obtained from product catalogues. *Nominal pressure. Full stent opening requires 9 atm. CoCr: cobalt-chromium; eptfe: expanded polytetrafluoroethylene Ismail Dogu Kilic, Coronary covered stents, Eurointervention, 20 November 2016

31 Material comparison table regarding Guide Catheter Extensions DEVICE BRAND COMBATIBLE GUIDING CATHETER INNER LUMEN GuideLiner 5,5 Fr Vascular Solutions 0,066 0,051 GuideLiner 6 Fr Vascular Solutions 6Fr / 0,070 0,056 GuideLiner 7 Fr Vascular Solutions 7Fr / 0,078 0,062 Guidezilla Boston Scientific Corporation 6Fr / 0,070 0,057 Mother in Child Heartrail Terumo 6Fr / 0,071 0,059

32

33 Summary How we can avoid this complication? Type III Ellis perforation is a rare but deadly complication, more frequent in calcified lesions, when high pressure dilatations are performed and when an overestimation in vessel diameter is done. A proper preparation in calcified plaques to treat can prevent it. Never underestimate calcified plaques. If you are in a doubt about the diameter of the vessel, be cautious and use other techniques (e.g. IVUS or OCT) in addition to angiography. Sometimes, The best is the enemy of the good (Voltaire) How we should manage this complication? Every cath lab should have a protocol to guide the treatment of this and other complications in order to combine a rapid response in cardiopulmonary resuscitation maneuvers and pericardiocentesis with the appropriate percutaneous treatment. It is very important that each person working in the cath lab is trained in the proper use of stentgraft implantation with slow inflation and deflation. The Ping-Pong Technique is helpful to minimize hemorrhage through the coronary perforation during interventional repair. Covered stent delivery through guide catheter extentions improves back up support through previous implanted stent Stentgraft are more thrombogenic than other stents, and an appropriate antiplatelet regimen should be prescribed.