Perforation Type 3 CS Device – Case 1
- 48-year-old male who presented with chest pain (CCS Class IV).
Past Medical History
- HTN, HLD, DM, CAD s/p Multiple PCI’s
- LVEF 60%
- Prior Cardiac Catheterization: RCA 100% thrombotic lesion s/p PCI.
- Home Medications: Aspirin, Clopidogrel, Rosuvastatin, Metoprolol Succinate, Ramipril
- Adjunct Pharmacotherapy: Prasugrel, Heparin IV
Pre-procedure EKG Heading
Left coronary artery angiography
- no significant disease and patent intervention sites in the left anterior descending (LAD) and left circumflex (LCx) coronary arteries.
- Underwent intervention of the distal RCA.
- Rotational atherectomy was performed with procedure being complicated by a RPDA perforation with contrast extravasation into the middle cardiac vein.
- Balloon tamponade failed to seal the perforation.
- Two PK Papyrus stents were placed, followed by post-dilatation of the stents, effectively sealing the perforation.
- Echocardiography showed no pericardial effusion.
- Troponin-I peaked at 4.0 ng/mL and CK-MB peaked at 36.7 ng/mL.
- Patient was discharged home the next day without further sequelae.
- What is the likely explanation or reason why the complication occurred?
- Rotational atherectomy related perforation.
- How could the complication have been prevented?
- Rotational atherectomy should be considered on a case by case bases, especially when the lesion is long, severely calcified and/or with severe angulation/tortuosity. In this case we should have been less aggressive with performing rotational atherectomy and considered performing cutting/scoring balloon angioplasty in the distal RCA/RPDA.
- Technical modifications to prevent rotablation related perforation:
- Use a small burr size (start with 1.25 burr)
- Bending the wire technique
- Use of Rota Extra Support wire
- Pre-dilatation with small balloon
- Avoid GP IIB/IIA prior to rotablation
- 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 it is 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?
- Need to be extremely cautious when using atherectomy devices, especially in tortuous vessels where there is increased guidewire bias, which increases the risk of dissection and perforation.
- Patients who have a cavity spilling perforation should be monitored closely with serial echocardiography to rule out possibility of developing a pericardial effusion/cardiac tamponade from an associated type 3 perforation.
- Usually, these patients do well without any intervention. In case of a large perforation, it is reasonable to consider definitive therapy including balloon tamponade, covered stent, etc.
- Delivery of a covered stent:
- A covered stent can be delivered using the same guide catheter after removal and retrieval of the balloon, if there is no significant hemodynamic decompromise and in the absence of a large perforation present. If using this strategy, an operator needs to act quickly because once the balloon is deflated, there will be ongoing coronary extravasation into the pericardial space.
- Alternatively, a second guide catheter strategy can be used for delivering a covered stent. To do this, obtain alternate access, advance a second guide catheter, disengage the first guide catheter and intubate the perforated artery with the new guide catheter (PING-PONG technique). Next, advance a second guidewire to the proximal edge of the inflated balloon, deflate the balloon, advance the wire to the distal vessel and then immediately re-inflate the balloon. The covered stent is advanced over the second guidewire until proximal to the inflated balloon. Then deflate the balloon and remove it along with the first guidewire (into the initial guide catheter), and quickly position the covered stent and immediately deploy it to high pressure. This should be followed by high pressure post-dilatation (18-20 atm) to achieve appropriate stent apposition.