Perforation Type 2 Wire – Case 2
- 55-year-old male who presented with chest pain (CCS Class II). Referred for IVBT of the RCA.
Past Medical History
- HTN, HLD, DM, CAD s/p PCI, Asthma
- LVEF 50%
- Stress MPI: Moderate size, reversible defect involving the inferior segment.
- Home Medications: Aspirin, Clopidogrel, Rosuvastatin, , Metoprolol Succinate, Ramipril, Hydrochlorothiazide, Sitagliptan, Metformin, Insulin, Pantoprazole
- Adjunct Pharmacotherapy: Clopidogrel, Bivalirudin
Pre-procedure EKG Heading
Right coronary artery (RCA) angiography
- 70-80% in-stent restenosis lesions in the mid and distal RCA.
- Underwent intervention (IVBT) of the of the RCA with procedure being complicated by a type 2 wire perforation.
- Perforation was adequately sealed with prolonged balloon tamponade of the vessel with residual staining of the myocardium.
- Echocardiography showed no pericardial effusion.
- Troponin-I peaked at 0.68 ng/mL and CK-MB peaked at 3.9 ng/mL.
- Patient was discharged home the next day without any sequelae.
- What is the likely explanation or reason why the complication occurred?
- Wire related perforation (Around 50% of coronary perforations are guide wire related).
- How could the complication have been prevented?
- Carefully manipulate the wire. Ideally, a wire should be positioned distal to a lesion in a large caliber vessel so long as it provides sufficient support to perform a coronary intervention.
- Using a workhorse, non-hydrophilic wire with tip load <1g when performing a coronary intervention helps reduce complications.
- 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?
- Appropriately frame the vessel and ‘pan’ when performing angiography to visualize the entire vessel. In this case, if we did not attain a follow up angiographic image a distal wire perforation could have been missed.
- Newton’s Third Law “For every action, there is an equal and opposite reaction”. When retracting a device back into the guide you need to be extremely cautious as the guide catheter tip and wire tip are likely to propel forward. The opposite can occur when advancing a device over a wire, leading to guide catheter disengagement and loss of wire position.
- When performing prolonged balloon inflation to tamponade the vessel, the balloon should be placed distal as possible in the vessel and immediately proximal to the location of the perforation in an appropriately sized vessel which can accommodate a 1:1 sized balloon. This is important because it helps prevent ischemia in a larger vascular territory.
- When performing prolonged balloon tamponade of a vessel, extreme caution needs to be take when removing the balloon, exchanging equipment and performing angiography as there is high risk for thrombus formation on the intracoronary equipment and within the guide catheter, especially if anticoagulation is stopped/reversed.
- It is essential to gently aspirate the guide catheter prior to injecting IC agents and contrast in order to reduce the risk of thrombus embolization.
- Pay close attention to the pressure tracing. Make sure a dicrotic notch is present and the pressure wave form is not dampened. This may be the first sign there is catheter is obstructed/thrombus has formed within the guide catheter.