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The Frame – Balloon Expanding

Clinical Presentation

  • 65-year-old male who presented with chest pain (CCS Class II).

Past Medical History

  • HTN, HLD, CAD s/p PCI, Active Tobacco Use
  • LVEF 60%

Clinical Variables

  • Stress MPI: Moderate anterior ischemia.

Medications Heading

  • Home Medications: Aspirin, Prasugrel, Atorvastatin, Metoprolol Succinate, Nifedipine, Omeprazole
  • Adjunct Pharmacotherapy: Prasugrel, Bivalirudin

Pre-procedure EKG Heading

Angiograms

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Left coronary artery angiography
  • 70-80% mid left anterior descending (LAD) lesion with a myocardial bridge.
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Left coronary artery angiography

  • 70-80% mid left anterior descending (LAD) lesion with a myocardial bridge.
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Right coronary artery (RCA) angiography

  • angiographically normal RCA.
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Deployment of a Xience Prime 2.5/38mm stent in the mid LAD.

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Angiography of the LAD after stent post-dilation (18 atm) showing a type 2 mid-stent perforation.

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Balloon tamponade of the mid LAD using a Quantum Apex 2.5/20mm balloon.

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Angiography of the LAD after prolong balloon tamponade of the vessel showing successful sealing of the perforation.

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Final angiography showing successful intervention and sealing of the perforation.

Post-procedure EKG

Case Overview

  • Underwent intervention of the mid LAD.
  • A stent was placed in the mid LAD (bridge segment) followed by post-dilation of the stent which resulted in a Type 2 perforation.
  • Perforation was sealed with prolonged balloon tamponade of the vessel.
  • Troponin-I peaked at 0.2 ng/mL.
  • Procedure was continued and patient underwent successful LAD-D2 bifurcation stenting.
  • Echocardiography showed no pericardial effusion.
  • Patient discharged home the next day without any sequelae.

Learning Objectives

  • What is the likely explanation or reason why the complication occurred?
    • Aggressive post-dilatation of an under-expanded stent located within a myocardial bridge segment.
  • How could the complication have been prevented?
    • Avoid over sizing the stent and high pressure post-dilatation of a stent, especially if the stent is placed in a myocardial bridge segment.
  • Is there an alternate strategy that could have been used to manage the complication?
    • Ellis Type 1 and 2 perforations usually seal spontaneously and are conservatively managed. Such patients should be closely monitored in the catheterization lab, and serial echocardiography should be performed, particularly if there is an Ellis Type 2 coronary perforation because it may lead to cardiac tamponade. Ellis Type 3 perforations are associated with increased risk of cardiac tamponade and mortality, and require immediate intervention/treatment. Ellis Type 3 Cavity Spilling perforation management is unclear. Usually they are conservatively managed, unless there is significant extravasation or the patient is symptomatic.
    • Coronary perforation management algorithm:
      • 1st: Prolonged balloon inflation: Position the balloon (or stent-balloon post stent deployment) just proximal or at the level of the perforation to prevent ongoing extravasation and development of hemo-pericardium. Ideally, the balloon to artery ratio should be 1:1. Inflate for 5-10 minutes followed by test deflations with contrast given in between inflations to evaluate the status of the perforation. If there is ongoing extravasation, re-inflate the balloon to stop further extravasation of blood into the pericardial space. This strategy helps stabilize the patients and gain control of the situation, while the operator prepares for echocardiography, pericardiocentesis, and more definitive treatment to seal the perforation.
      • 2nd: Anticoagulation management: ‘STOP’ all anticoagulation immediately if you suspect or visualize a perforation. We consider ‘REVERSING’ heparin with protamine sulfate (to achieve ACT <225s) after coronary equipment is removed to prevent thrombosis within the vessel. If using bivalirudin, it can take up to 1-2 hours for its anticoagulation effect to a normalize after it is stopped. If patient was on glycoprotein IIB/IIIA inhibitors: For abciximab, consider giving platelet transfusion; tirofiban and eptifibatide have a short half life and their reversal can typically be achieved by stopping there infusion or in extreme cases with hemodialysis. Cangrelor has a short half life and its reversal can be achieved by stopping its infusion.
      • 3rd: Covered stent: Standard of care for a perforation located in the proximal to mid segment of a vessel of appropriate size (≥2.5 mm), with no major side branch across the region where the stent will be placed. If a covered stent can be delivered to a distal vessel perforation, and the vessel is of appropriate size, covered stent placement to seal the perforation is reasonable. If the clinical situation allows, proceed with direct stent placement whenever possible using a single catheter or two-catheter (Ping-Pong) strategy. The stent should be quickly positioned and immediately deployed to high pressure. This should be followed by high pressure post-dilatation (18-20 atm) to achieve appropriate stent apposition.
      • 4th: Embolization of distal vessel perforations: Non-surgical techniques for distal vessel embolization include: Coils, Gel Foams, Glues, Microspheres, Thrombin injection, Subcutaneous tissue, Autologous Blood Clots and multiple other agents (depending on what is available in an individual catheterization lab). Embolization leads to loss of vessel flow beyond point where embolized material is delivered and subsequent infarct in the vessel territory.
      • 5th: Surgery Intervention: Ligation or suturing of the vessel for hemostasis with bypass grafting to the distal vessel. Pericardial patch/Teflon with possible bypass grafting to the distal vessel (consider this approach if vessel has multiple stents and/or presence of a subepicardial hematoma).
  • What are the important learning points?
    • Techniques associated with perforations: use of hydrophilic/extra stiff wires, atherectomy devices, cutting balloons, increase balloon-to-artery ratio, high pressure post-dilatation of stent.
    • Angiographic findings associated with perforations: CTO, severe calcification, type C lesions, eccentric lesions, RCA or LCx lesion, tortuous vessels.
    • If a diseased segment of a vessel involves a myocardial bridge, extreme caution is warranted when performing an intervention because there is increased risk for complications.
    • Maximal medical therapy should be considered for treatment of a diseased segment involving a myocardial bridge or a symptomatic myocardial bridge (using beta-blocker therapy). If the patient has refractory symptoms despite maximal medical therapy, PCI can be considered.
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