“an iatrogenic ellis type iii coronary perforation, in ... · “an iatrogenic ellis type iii...
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“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, MDCardiologistUniversity Cardiology DptMedical School, Democritus University of Thrace, Alexandroupolis, Greece
Disclosures
None to be declared
Case Presentation
A 58-year-old woman with a history of diabetes mellitus, dyslipidemia,and hypertension was referred for cardiac catheterization due tocrescendo angina pectoris. A myocardial scintigraphy study (SPECT)showed a large reversible anterior wall perfusion defect that indicatedLAD ischemia.
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
Case Presentation
• Vitals signs at admission time: HR 75 beats/min, BP 120/80 mmHg
• Pre procedure medications:
- 180 mg Ticagrelor p.o.
- 325 mg Aspirin p.o.
- 2500 U Heparin i.v.
Baseline Angiography
Left coronary angiogram showing the severe proximal-LAD lesion and the distal LAD lesion
Access: right radial artery Sheath: 6F GlideSheath Terumo with outer diameter 5F
Diagnostic catheter: 5F Tiger 4,0
Τreatment of proximal LAD Lesion
Postdilation with a 4 x 25 mm NC Balloon after Stent Deployment(18 Atm)
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)
Angiographic result in Prox. LAD Lesion
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)
Post-stenting angiographic result
• IVUS showed that the distal LAD stent was under-expanded and malapposed, as shown in the picture
IVUS showed that the distal LAD Stent was under-expanded and malapposed
• So, from IVUS we found that the Minimum Stent Area is under 5 mm 2 and we decided to proceed to postdilatationusing a NC Balloon 2,75 mm which we believe, according to the measurements we made with IVUS, was the rightchoice. Based on the multiple measurements of IVUS, the reference vessel diameter was 3 mm and knowing that theintracoronary ultrasound overestimates the diameter from 0.25 to 0.5 mm in comparison to QCA we chose a ΝCBalloon 2,75 mm.
• 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 yousee a plaque which is, indeed, of mixed echogenicity, that is to say it has acalcareous element which gives this acoustic shadow behind.
Postdilatation of distal LAD Stent
Postdilatation of distal LAD stent with a 2,75 x 26 mm Non- compliant balloon (18 Atm)
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.
Prolonged balloon Inflation
*ACT 240:No Reversal of Anticoagulation
Pericardiocentesis
500 ml blood
drained
Persistent extravasation in spite of prolonged balloon inflation for 20 Μinutes
Insertion of a second Guide Catheter forcovered stent delivery
The Ping-Pong Technique
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 stentdelivery specifically in spiral or calcified segments of the vessel or through already existent stents, like a “distal anchoringtechnique“.
ReferenceTreatment with the Double Guiding Catheter Technique for Type III Coronary PerforationRev bras Cardiol Invasiva 2013: 21:401-5 vol.21
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)
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
Final angiographic result
• A contrast echocardiography was immediately performed for theexclusion of an active extravasation into the pericardium. A smallpericardial 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 theincident. There were no signs of ischemia.
Follow-up
Type I Extraluminal crater without extravasation
Type II Pericardial or myocardial blush without contrast jet extravasation
Type III Extravasation through frank (>1 mm) perforation
*Type III cavity spilling (CS) Perforation into an anatomic cavity, chamber, coronary sinus, etc.
*Sometimes referred to as Type IV
Ellis Classification of Coronary Perforation
Harries I et al,Eurointervention, 2014 Sep;10(5):646-7 Ellis et al,Circulation,1994;90;2725-2730
Ellis Classification of coronary Perforation
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 isfrequently benign
• Collateral perforation
- occur in CTO PCI
- Epicardial collateral → Treatment includes both sides of the perforation(donor and recipient vessel)
Device Total Class II Class III
Guidewire 10 2 8
Stent 14 1 13
Cutting balloon 5 3 2
Post-dilatation 7 1 6
Predilatation 6 1 5
Late 2 0 2
Mechanism of Coronary Perforation
Hendry et al Eurointervention 2012 May 15;8(1);79-86
Several factors can be associated with Coronary Artery Perforation
Risk Factors:
Clinical Procedural
Complex lesions Atheroablative devices
Age Cutting balloons
Female gender Hydrophilic guidewire
Chronic total occlusion
Stiff guidewire
Presence of coronary calcification
Use of IVUS
Hypertension Oversized device
Acute coronary syndrome
Femoral approach
Heart failure
Harries I, Eurointervention 2014
Type 1 Perforation Management
Watchful waiting
Type 2 Perforation Management
➢Hydrophilic / CTO wires➢Distal perforation➢Embolisation:
• coils• thrombin• gelfoam / microshpheres•negative pressure suction via microcatheter•blood clot• subcutaneous fat
Type 3 Perforation Management
➢Prolonged balloon inflation (tolerated)➢Cardiac Tamponade - Pericardiocentesis➢Covered stent / 2nd guiding catheter➢Reverse anticoagulation (only if ACT is
greater than it should be)➢Surgery
Treatment Algorithmus of Grade III CoronaryPerforationsGrade 3 coronary perforation
Prolonged balloon inflation
Pericardiocentesis, cardiopulmonary resuscitation +/- IABP as necessary
Covered stent implantation
• Prolonged balloon inflation with IABP support• Coil embolization, if feasible• Surgical repair of perforation +/-
CABG
• Postdilatation of covered stent• Further covered stent implantation• Prolonged balloon inflation +/- IABP
support• Coil embolization, if feasible• Surgical repair of perforation +/- CABG
Heparin reversal +/- platelet
transfusion as necessary
No further treatment
Heparin or Gpllbllla
administered?
Evidence of continued contrast extravasation despite prolonged balloon inflation or intolerance to prolonged balloon inflation?
Evidence of continued contrast extravasation?
Hemodynamically unstable?
No further treatment
Yes
Intolerance to prolonged
balloon inflation
Yes
Distal coronary perforation or covered stent undeliverable
No
No
Yes
Yes
Al-Lamee R et all, JACC Cardiovasc Interv. 2011 Jan;4(1):87-95
Ismail Dogu Kilic, Coronary covered stents, Eurointervention, 20 November 2016
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/designStainless steel
(316L)Sandwich design
Cobalt-chromium(L-605)
Single layer
CoCr (L-605) with amorphoussilicon carbide coating
Single layer
Stainless steel(316L)
Single layer
Guide catheter compatibility6 Fr (≤4.00 mm)
7 Fr (4.5 and 4.8 mm)5 Fr 5 Fr (stents <4.0mm)
6 Fr (stents ≥4.0mm)6 Fr
Crimped profile 1.63-1.73 mm 1.1-1.4 mm 1.18-1.55 mm 1.26-1.41 mm
Stent diameter (mm) 2.8-4.8 2.5-5.0 2.5-5.0 2.5-4.0
Stent length (mm) 16-26 8-24 15-26 13-27
Nominal implantation pressure15 atm 11 atm (2.5-4.0 mm)
10 atm (4.5-5.0 mm)8 atm (2.5-3.5 mm)7 atm (4.0-5.0 mm)
5 atm*
Information obtained from product catalogues. *Nominal pressure. Full stent opening requires ≤9 atm. CoCr: cobalt-chromium; ePTFE: expanded polytetrafluoroethylene
Covered Stents available in Europe
Material comparison table regarding Guide Catheter Extensions
DEVICE BRAND COMBATIBLEGUIDING 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”
SummaryHow we can avoid this complication?
➢ Type III Ellis perforation is a rare but deadly complication, more frequent in calcified lesions, when high pressure dilatations areperformed 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 incardiopulmonary 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 inflationand 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.