PERFORATION and RUPTURE

Transcription

1 PERFORATION and RUPTURE Dr. Enrique Esplugas Hospital Universitari de Bellvitge L Hospitalet de L. Barcelona. SPAIN I do not have any potential conflict of interest

2 PERFORATION RUPTURE Disruption of the vessel wall through the intima, media and adventitia Incidence: % Guide - Wire Perforation (distal) Balloon Stent Atherectomy Rupture (lateral)

3 RISK FACTORS Guide-Wire distal-end stiffness Hydrophilic coated wire ( spontaneous sliding ) Older age Female gender Safenous vein Severe calcification High balloon stent-to-artery ratio. Postdilation Atherectomy devices. Cutting balloon CTO High-pressure jet due to balloon rupture

4 CLASSIFICATION (Ellis et al. Circulation 1994; 90 : ) Type I : Extraluminal crater without extravasation. Type II : Pericardial or myocardial blush without contrast jet extravasation. Type III : Extravasation through franc ( >1 mm) perforation. Type IV : Spilling into anatomic cavity chamber o cardiac vein.

5 TYPE I Usually no futher complications Stent Retrieval of guidewire Wait and see

6 Type I : Extraluminal crater without extravasation.

7 Left Coronary Artery Type I. Example

8 DES Type I. Example

9 Result after DES Type I. Example

10 Left Coronary Artery Type I. Example

11 TYPE II High rate of only percutaneous management Prolonged balloon inflation (at or proximal) Protamine sulfate. Platelets ( IIb / IIIa) Pericardiocentesis? Stent (Stent Graft, M Guard)? Coils?

12 Type II: Pericardial or myocardial blush without contrast jet extravasation

13 2,5x16 BMSStent. Type II. Example 1

14 No symptoms. ACT 500 seg. Type II. Example 1

15 Infusion catheter (3F). Embolization with autologous fat tissue. Type II. Example 1

16 Easy to reach, easy to remove Type II. Example 1

17 Good clinical evolution. Type II. Example 1

18 Type II: Pericardial or myocardial blush without contrast jet extravasation

19 Type II. Example 2

20 Implantación stent mm Type II. Example 2

21 Balón 4-16 mm Type II. Example 2

22 Type II. Example 2

23 Protamina e implantación stent mm Type II. Example 2

24 Type II. Example 2

25

26 Right coronary artery Type II. Example 3

27 Angigraphy after rotablator. Severe hypotension Type II. Example 3

28 After Balloon predilatation. Type II. Example 3

29 Final result Type II. Example 3

30 TYPE III Dramatic. Life threatening Prolonged balloon inflation (at or proximal). Protamine sulfate. Platelets ( IIb / IIIa). Pericardiocentesis. Resuscitation measures. Coil. Microsphere. Adipose tissue. Thrombin (distal). Stent Graft (lateral). Emergent cardiac surgery.

31 Type III : Extravasation through franc ( >1 mm) perforation

32 Type III. Example 1

33 Type III. Example 1

34 Final result Type III. Example 1

35 Type III : Extravasation through franc ( >1 mm) perforation

36 Hypotension. Tamponade checked by TTE. Type III. Example 2

37 Pericardiocentesis+protamine+balloon dilation for 11 min. Current ACT: 120 seg Type III. Example 2

38 Control after protamine+balloon. Type III. Example 2

39 Platelet+blood transfusion Polivynil-OH microparticles through an inflated 1,5 OTW balloon Type III. Example 2

40 Good evolution. Small AMI. 48h TTE: no effusion Type III. Example 2

41 Type III : Extravasation through franc ( >1 mm) perforation

42 Type III. Example 3

43 Type III. Example 3

44 Type III. Example 3

45 Type III. Example 3

46 Type III. Example 3

47 Type III. Example 3

48 Type III : Extravasation through franc ( >1 mm) perforation

49 Implantación stent mm Type III. Example 4

50 Sobredilatación balón mm Type III. Example 4

51 Inflado prolongado y protamina Type III. Example 4

52 Type III : Extravasation through franc ( >1 mm) perforation

53 Type III. Example 5

54 Predilatción con balones 3-20 mm y mm Type III. Example 5

55 Predilatación con Balón de Corte Type III. Example 5

56 Type III. Example 5

57 Type III. Example 5

58 TYPE IV Non emergent Wait and see. Coils (distal). Stent Graft (lateral).

59 Type IV : Spilling into anatomic cavity chamber o cardiac vein

60 Coronaria Derecha Type IV. Example 1

61 Resultado tras las dilataciones Type IV. Example 1

62 Ecocardio inmediato post ICP Type IV. Example 1

63 Ecocardio inmediato post ICP Type IV. Example 1

64 Ecocardio control a los 2 meses Type IV. Example 1

65 Type IV : Spilling into anatomic cavity chamber o cardiac vein

66 Right Coronary Artery Type IV. Example 2

67 2.25x24 mm DES Type IV. Example 2

68 Type IV. Example 2

69 Control angiography 3 months later Type IV. Example 2

70 Type IV : Spilling into anatomic cavity chamber o cardiac vein

71 Type IV. Example 3

72 Post-dilatación balón mm Type IV. Example 3

73 Type IV. Example 3

74 Implantación stent mm Type IV. Example 3

75 Type IV. Example 3