Coronary perforations detection management

Coronary  Perfora+ons   Detec%on  &  Management   Nguyen  Ngoc  Quang,  MD,  PhD,  FASCC,  FSCAI   Consultant  of  Interven/on  Cardiology   Head  of  Coronary  Care  Unit,  Vietnam  Na3onal  Heart  Ins3tute,     Department  of  Cardiology,  Hanoi  Medical  University   Complica+ons  during     percutaneous  coronary  interven+on   Complica+ons  during     percutaneous  coronary  interven+on   Literature  review   -­‐  In almost 200000 unselected pts – 0.43%   -­‐  In selected pts 1% -­‐ >10% (CTO)   -­‐  Ellis  classifica+on  most  important:              tamponade:  I/II  –  8-­‐13%,  III  –  63%   Shimony A et al Coronary Artery Perfora3on During Percutaneous Coronary Interven3on: A Systema3c Review   and Meta-­‐analysis Can Card J 2011;27:843-­‐850   Risk  factors  for  coronary  perfora+on   •  Pa+ent-­‐related  risk  factors:  older  age;  previous  CABG;  lower   crea/nine  clearance   •  Angiographic  risk  factors:  type  B  or  C  lesions;  CTO,  calcified,   tortuous  and  angulated  lesions;  small  vessel   •  Procedure-­‐related  risk  factors   –  Atheroabla/ve  devices   –  Hydrophilic  guide  wires  (not  all  studies)   –  Balloon  infla/on:  outside  stent;    oversized  balloons  (>1.2)   –  Sten/ng  of  tapering  vessel,  lesions  that  are  re-­‐crossed  aNer   severe  dissec/on  or  abrupt  closure   –  CTO  sten/ng  in  some  cases  (large  dissected  space)   Ajluni SC, et al Cathet Cardiavasc  Diagn 1994;     Stankovic G, et al Am J  Cardiol 2004;     Shimony A, et al Can Card J 2011;27:843-­‐850   Be  aware  that  it  is  happening  !   Hypotension  3h  aUer  PCI   Hypotension  5h  aUer  PCI   Massive  perfora+on  is  not  always  obvious   Be  vigilant  to  detect  early  the  “poten%al”  massive  perfora%on!   1.  Clinical  signs:     •  Asymptoma/c  but  hemodynamic  collapse  (esp  late  phase)   •  Acute  pain  (chest,  neck,  throat),  vagal  symptoms,  hypotension  ±   tachycardia,  ventricular  ectopy…  aNer  high-­‐risk  procedural  step   2.  Fluoroscopic  signs:       •  Contrast  extravasa/on,     •  Errant  wire  posi/on,     •  “Dead  heart”  sign  with  massive  tamponade   3.  Angiographic  signs:  5  types  of  Ellis  classifica/ons   •  Extraluminal  crater  without  extravasa/on   •  Pericardial  or  myocardial  blush  w/o  contrast  jet  extravasa/on   •  Ac/ve  jet  extravasa/on  towards  pericardium   •  Cavity  spilling  (coronary  sinus,  cardiac  chambers…)   •  Distal  perfora/on     Ellis  SG  et  al  Circula3on  1994;90:2725–30   Shimony  A  et  al  Can  Card  J  2011;27:843-­‐850     Obvious   perfora3on   aUer  post   dila3on  with   non-­‐   compliance   balloon!   Differen+ate  what’s  happening   Hypotension  during  CTO  procedure   No  tamponade  on  ultrasound   First  reac%on  for  perfora%on   Prolong  balloon  infla/on  to  stop  the  blood  flow  before  the  perfora/on  site   Ini+al  management     1.  2.  3.  4.  5.  Prolong  balloon  infla/on   Fluid  resuscita/on  and  inotropic  transfusion   Reverse  an/coagula/on   Immediate  prepara/on  for  pericardiocentesis       …    Management  flowchart  for  perfora+on   What  If  there  is   no  covered  stent   available  !!!     Al-­‐Lamee  R,  et  al  J  Am  Coll  Cardiol  Interv  2011;4:87-­‐95   Promptly  bedside  pericardiocentesis   Pericardiocentesis  if  hemodynamic  collapse  aNer  prolong  balloon  infla/on;   fluid  resuscita/on  and  inotropic  transfusion  and    reverse  an/coagula/on…   Cura+ve  management  for  perfora+on   1.  Covering  for  proximal  perfora%ons:     •  Prolonged  balloon  infla/on,     •  Extra  stents   •  Cover  stent,  stent  sandwich,  vein-­‐covered  stent…       2.  Emboliza%on  for  distal  perfora%ons:     •  Thrombogenic  vascular  coils,  gelfoam,  polyvinyl  alcohol,   pre-­‐clo_ed  autologous  blood  clot,  glue,  thrombin   •  Autologous  fat,   3.  Open-­‐heart  surgery  for  uncontrolled  perfora%ons   Good  final   result  aMer   puNng     extra  stent   Hand-­‐made  “stent  sandwich”   XXX   Balloon  layer     Inflate  1st  stent  to   unmount  the  fully   expanded  stent  and       to  get  the  balloon  coat   Cut  both  ends   of  the  balloon   to  shorten  the   balloon  coat   Put  the  cut  balloon   over  a  2nd  new  stent   then  reeve  all  through   the  1st  expanded  stent   Crimp  and  roll   the  assembled   system  un/l  it   is  solid  &  ready       XXX   sure  the  hand-­‐ XXX   Make   made  stent  sandwich   smooth  to  pass  the   guiding  catheter   Pienvichit  P,  et  al  Cathet  Cardiovasc  Intervent,   2001;54:209-­‐13   A  balloon  coat   trapped  by  two   layers  of  stent   would  cover   the  perfora/on   Covering  for  proximal  perfora+ons   Solu+on   Advantage   Prolonged  balloon   -­‐  -­‐  Limita/on   -­‐  -­‐  Tips  and   tricks   Always  be  the   first  choice:   fast  and  easy   Predilata/on   for  bulky   device   Need  longer   /me,  close   monitor  of   vital  signs  and   pericardial   fluid  on  echo   Uncertain   sealing   immediately   Extra  stents   -­‐  -­‐  -­‐  -­‐  Stent  sandwich   Cover  stent   Fast  and  easy   -­‐  deployment   Can  put  more   un/l  having  no   perfora/on     Certain  sealing   -­‐  immediately,   then  can  avoid   a  sternotomy     Certain  sealing   immediately,   then  can  avoid   a  sternotomy   Uncertain   sealing   immediately   Can  worsen   perfora/on   Need  prepare,   bulky  profile,   easily  dislodge   Not  suitable   for  complex   anatomy   Uncertain   future  (late   occlusion  )   Big  profile   Size  not  always   available     Not  suitable   for  complex   anatomy   Uncertain   future  (late   restenosis)   -­‐  -­‐  -­‐  -­‐  -­‐  -­‐  -­‐  Ellis  type  I,III,  even   Ellis  type  III  at  LM,   Ellis  type  III  at  pRCA,  side  branches  (D,   III  (small,  self   mLAD,  pLCX,   OM…)  or  when  other  solu3ons  failed     stained  w/o   mRCA,  na3ve   pericardial  fluid)   vessel  post  CABG…   Anatomy-­‐driven  solu+ons  for  perfora+on   Sealing  distal  perfora+on   by  autologous  fat  +ssues   Follow-­‐up  Treatment   •  Pa/ent  was  sent  to  CICU  to  follow-­‐up  for  24-­‐48  hour     •  The  pigtail  was  removed  the  next  day   •  Rou/ne  an/platelet  therapy  were  restarted  aNer   pericardial  drainage  stopped  Blood  transfusion  might   be  needed   •  Be  careful  with  Dressler  reac/on   •  Pa/ent  discharged  and  follow-­‐up  are  necessary   Preven%ve  %ps  for  perfora%on   1.  Careful  manipula/on  of  the  wire;  avoid  leaving  in   small  branch;  posi/on  of  the  /p  checked  frequently   2.  ANer  defla/on  of  the  balloon,  keep  the  balloon  in   place,  check  ECG  and  pain  relief,  then  make  small   injec/on  Do  not  remove  the  balloon  unless   everything  is  clear   3.  The  covered  stent  is  bulkier,  proximal  dila/on   needed,  as  well  as  body  wire   Nguyen TN, et al Prac3cal handbookof advanced interven3onalcardiollogy 3rd ed Blackwell Futura 2008   Take-­‐home  messages   •  Be  vigilant:  massive  coronary  perfora/on  can  happen   early  during  PCI  procedure  or  late  during  first  24   hour  follow-­‐up   •  Understand  clear  how  a  lesion  behave  before  any   risky  step       •  Consider  appropriately  extra  stent  or  stent  sandwich   following  various  clinical  scenario,  in  case  of  no   covered  stent  available     •  Be  calm  and  cool  to  deal  with  complica/ons!   Thank  you  very  much  for  your  aien+on   [...]...Ini+al management     1.  2.  3.  4.  5.  Prolong  balloon  infla/on   Fluid  resuscita/on  and  inotropic  transfusion   Reverse  an/coagula/on   Immediate  prepara/on  for  pericardiocentesis       …   Management  flowchart  for  perfora+on   What  If  there  is   no  covered  stent   available  !!!    ...  bedside  pericardiocentesis   Pericardiocentesis  if  hemodynamic  collapse  aNer  prolong  balloon  infla/on;   fluid  resuscita/on  and  inotropic  transfusion  and    reverse  an/coagula/on…   Cura+ve management  for  perfora+on   1.  Covering  for  proximal  perfora%ons:     •  Prolonged  balloon  infla/on,     •  Extra  stents   •  Cover  stent,  stent  sandwich,  vein-­‐covered  stent…       2.  Emboliza%on...  dila/on   needed,  as  well  as  body  wire   Nguyen TN, et al Prac3cal handbookof advanced interven3onalcardiollogy 3rd ed Blackwell Futura 2008   Take-­‐home  messages   •  Be  vigilant:  massive coronary  perfora/on  can  happen   early  during  PCI  procedure  or  late  during  first  24   hour  follow-­‐up   •  Understand  clear  how  a  lesion  behave  before  any   risky  step       •  Consider