Perforation Type 3 CS Wire – Case 2
- 82-year-old female who presented with chest pain (CCS Class II) and was referred for staged PCI of the RCA.
Past Medical History
- HTN, HLD, CAD s/p multiple PCI’s, Former Tobacco Use
- LVEF 60%
- Stress MPI: Moderate to severe, reversible perfusion defect seen in the lateral wall concerning for ischemia.
- Prior Cardiac Catheterization: Mid LAD 50-60% In-Stent restenosis; Ostial D1 80-90%, stent jailed; Proximal LCx CTO, fills by collaterals from the RCA; Distal RCA 80-90% in-stent restenosis; RPDA 80-90% in-stent restenosis. S/p successful intervention of LCx with use of RA.
- Home Medications: Aspirin, Clopidogrel, Atorvastatin, Atenolol, Lisinopril, Alprazolam, Omeprazole
- Adjunct Pharmacotherapy: Clopidogrel, Bivalirudin
Pre-procedure EKG Heading
- a patent intervention sites in the left circumflex (LCx)
- 50-60% in-stent restenosis lesion in the mid left anterior descending (LAD) coronary artery.
- Underwent intervention of the RCA with use of rotational atherectomy.
- Distal RCA lesion was pre-dilated leading to a type b dissection.
- Procedure was continued and a stent was placed successfully, treating the lesion/dissected segment.
- A second stent was then placed in the RPDA.
- Procedure was further complicated by a type 3-CS RPDA-septal perforation with contrast extravasation into the middle cardiac vein.
- Perforation was inadequately sealed with prolonged balloon tamponade of the vessel.
- Patient remained hemodynamically stable, and without symptoms. Further intervention with placement of a covered stent was deferred.
- Patient was monitored on the cardiac catheterization table and remained hemodynamically stable.
- Echocardiography showed presence of a trivial pericardial effusion without tamponade physiology.
- Troponin peaked at 5.44 ng/mL and CKMB peaked at 22.8 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?
- Careful manipulation of 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.
- Extreme caution needs to be taken when using a hydrophilic wire (i.e. Fielder, Whisper wires etc.). Hydrophilic wires are more prone to cause a perforation as they tend to navigate into smaller branch vessels and provide less tactile feedback.
- 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?
- 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.
- 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.