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Wire Bias – Case 1

Clinical Presentation

  • 71-year-old male who presented with chest pain (CCS Class II) and was referred for staged PCI of the LCx-LPL1.

Past Medical History

  • HTN, HLD, Former Tobacco Use, CAD s/p PCI, PAD, Rheumatoid Arthritis
  • LVEF 62%

Clinical Variables

  • Prior Cardiac Catheterization: OM1 50-60% stenosis, LPL1 80-90% stenosis, proximal RCA subtotal, mid RCA 80-90% stenosis. S/p successful PCI of the RCA.

Medications

  • Home Medications: Aspirin, Clopidogrel, Atorvastatin, Metoprolol Succinate, Amlodipine, Isosorbide Mononitrate
  • Adjunct Pharmacotherapy: Clopidogrel, Bivalirudin

Pre-procedure EKG

Angiograms

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Right coronary artery (RCA) angiography
  • patent intervention sites in the proximal and mid RCA.
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Right coronary artery (RCA) angiography

  • patent intervention sites in the proximal and mid RCA.
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Left coronary artery angiography

  • 80-90% calcified lesion in the first left posterolateral branch (LPL1).
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Rota Floppy wire was positioned and rotational atherectomy of the LCx with a 1.25mm burr at 150k RPM was performed.

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Angiography of the LCx after rotational atherectomy showing significant wire bias and a type D dissection.

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Angiography of the LCx showing significant wire bias and a type D dissection.

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Guidezilla support catheter used to deliver a Trek 20/12mm balloon to the LPL branch, followed by pre-dilatation of the LPL lesion.

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Deployment of a a Xience Sierra 2.5/28mm stent in the LPL branch.

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Positioning of an Xience Sierra 3.0/28mm stent, overlapping with the proximal stent edge of the previously placed stent in the LPL branch.

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Angiography after placement of two stents showing successful treatment of the type D dissection and the presence of a hematoma along with plaque shift into the ostium of the OM2.

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Balloon dilatation of the distal stent edge in the LPL branch with a Trek NC 2.5/12mm balloon.

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Angiography of the LCx-LPL branch after lesion balloon dilated.

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Final angiography showing successful intervention and treatment of the type D dissection.

Post-procedure EKG

Case Overview

  • Underwent intervention of the LCx.
  • Procedure was complicated by a type D dissection following rotational atherectomy due to severe wire bias.
  • Dissection was successfully treated with placement of two overlapping stents.
  • Troponin-I peaked at 0.56 ng/mL and CK-MB peaked at 6.6 ng/mL.
  • Patient was discharged home the next day without further sequelae.

Learning Objectives

  • What is the likely explanation or reason why the complication occurred?
    • Wire bias altering the trajectory of the rotational atherectomy device.
  • How could the complication have been prevented?
    • Use of a guide catheter which provides coaxial engagement helps reduce unfavorable guidewire bias.
      • Pay close attention to the ACT during the procedure and dose anticoagulation accordingly to maintain ACT >300 prior to performing an intervention (Hemochron machine).
      • Avoid performing rotational or orbital atherectomy in vessels which are highly tortuous with severe wire bias. As an alternative, consider performing laser atherectomy, intravascular Lithotripsy (IVL) (off label use in the USA), cutting balloon angioplasty for plaque modification and/or treatment of calcified CAD.
    • Is there an alternate strategy that could have been used to manage the complication?
      • Wire bias could have possibly been prevented by use of a Rota Extra Support wire instead of a Rota Floppy wire.
        • A stiffer wire can sometimes be used to straighten the vessel or lesion to lessen the resistance and possibly reduce wire bias.
      • What are the important learning points?
        • This is a Type D dissection because of the presence of a spiral filling defect which is clearly outlined with persistence of extraluminal contrast which is present after contrast injection.
        • Need to be extremely cautious when using atherectomy devices in extremely tortuous vessels. Wire bias is more likely to occur in tortuous vessels and it increasing the risk of dissection or perforation.
        • Guidewire bias is when you have divergence from the central axis of the vessel and can result in ablation of normal tissue if the tension on the wall exceeds the elasticity of the vessel. To reduce sidewall tension:
          • Keep the tip of the guidewire just beyond the lesion
          • Use a stepped-burr approach starting with an undersized burr is preferred
          • When advancing the burr, do so at low speed to reduce there is less tension in the wire
        • There are two kinds wires that can be used when performing rotational atherectomy:
          • Rota Floppy Wire: Used in most cases, and is more flexible with a longer taper and shorter spring tip compared with the Rota Extra Support wire. This wire causes less vessel straightening, less wire bias, and allows for atherectomy along the greater curvature of an angulated lesion.
          • Rota Extra Support Wire: Used in tortuous vessels or in situations when one suspects wire bias as a reason for the burr not crossing the lesion. Wire is stiffer, and with a shorter taper and longer spring tip compared with the Rota floppy wire. This wire causes the vessel to straighten out the tortuosity to allow the burr to advance to a lesion, and is useful in ablation of plaque at the lesser curvature of angulated lesions, aorto-ostial lesions and distal lesions. However, this wire can result in proximal vessel spasm and ‘pseudo-stenosis’.
        • A stiffer guidewire does not always result in unfavorable bias, and may result in a favorable bias, particularly when performing rotabalation of an angulated and heavily calcified lesion.
        • Once a dissection is identified, rotational atherectomy should be stopped, and primary focus should be on maintaining wire position. After confirming the wire is in the true lumen, the dissection should be treated accordingly with balloon inflation and placement of a stent.
Educational Content

DEVICE EMBOLIZATION

  • Device embolization is a rare PCI complication defined as a loss of a device such as stent, guidewire, catheter fragments or misplaced intravascular coils within the coronary vasculature
  • Incidence - Stents are the most common devices embolized, with an incidence ranging from 3% for the first-generation hand-crimped devices to much lower, 0.32%, for current stent delivery system15
  • Risk factors:16
    • Extreme tortuosity
    • Angulation
    • Calcified vessels
    • Inadequate guide catheter support
    • Older generation stents
  • Device dislodgement may result in systemic or intracoronary embolization. While systemic embolization may cause severe cerebrovascular events, limb ischemia, death and the need for an emergency surgery, intracoronary embolization is associated with high risk of coronary thrombosis and subsequent MI17
  • A tortuous and calcified coronary anatomy increases the rigidity of the vessel making it prone to a stent peeling off the balloon as increased force is applied to advance the device. For this reason, stents are more commonly lost in the right coronary and left circumflex arteries and less commonly in the left anterior descending artery9
  • Prevention - When facing difficulty delivering a stent:
    • Stop and gently retract stent back into the guide catheter and remove it instead of forcing it forward
    • Perform pre-dilatation of the lesion if a direct stenting was attempted or if lesion was predilated perform further dilation using higher atmospheric pressure or bigger balloon or use atheroablative devices for adequate lesion preparation
    • Make sure the tip of guide is coaxial especially if there is significant proximal tortuosity
    • Use of guide extension catheters can help deliver the stents
  • Management - These are the key steps for managing device embolization during PCI:
    • If embolized item is a small guidewire, consider leaving wire in the coronary artery
    • No treatment is required for peripherally embolized small stents
    • Consider surgical removal if involves larger coronary arteries or difficult vascular access sites or if all the techniques fail to retrieve the device
    • Balloon assisted stent retrieval - After withdrawal of the stent balloon from which the stent has become dislodged, a second smaller 1.5 or 2 mm balloon is advanced over the wire and through the stent, and is inflated distal to the stent. Then it is retracted back into the guide. In some cases, the stent may be contained within the distal tip of the guide, but the inflated balloon cannot be retracted into the guide. In this scenario, the guide and balloon should be removed as one unit over the wire. Two balloons are required if the stent diameter is too large for a single balloon to retract.
    • Snare removal - This is the most widely used tool for stent retrieval. Many snares are available commercially; gooseneck snare is most commonly used. Once a stent slips off the delivery balloon, the indwelling wire is advanced as far as possible into the distal vasculature. The loop of the snare is passed over the angioplasty wire, encircles it, and is advanced up to the coronary ostium. It arrives at the right position as its loop is encircling the proximal end of the stent. The loop is tightened by advancing the transport catheter, and the whole stent–snare–wire complex is withdrawn as a unit.
    • Wire braiding assisted stent retrieval - This method is useful if the stent has come off the balloon but remains on the wire. A second, soft-tipped wire is navigated strategically through the side struts and not the central lumen. It is then passed into a branch distal to the stent and is separate from the first wire. Torque is then applied to both wires, and the twisting action results in them wrapping around both sides of the stent, trapping the stent in between. With gentle and persistent pulling, the whole system (guide, stent twisted between two wires) can be withdrawn. An extension catheter can be used to help retrieve the stent.
    • Deployment of embolized stent/Stent crushing or stent exclusion - If attempts for retrieval are unsuccessful, it may be necessary to consider stent crushing to the arterial wall with balloon inflation or deployment of an additional stent alongside the embolized one, although this is associated with an elevated risk of periprocedural MI, death, and referral for CABG. Even if the stent is not advanced completely through the lesion, it should be expanded where it is to its fullest possible dimension using the deployment balloon. If the deployment balloon cannot be advanced through the stent, a balloon with a lower profile should be inserted.




OSTIAL PCI COMPLICATION

  • Percutaneous intervention of ostial lesions in coronary arteries or aortocoronary bypass grafts can pose unique challenges and is associated with higher procedural and medium-term complication rates.21
  • Ostial lesion is defined as one arising within 3 mm of the vessel origin. It may be categorized by location as- Aorto-ostial, non aorto-ostial and branch ostial.22
  • In the balloon angioplasty era, procedural complications such as dissections, acute vessel closure and myocardial infarction were more frequent.23 This led to interest in the use of adjunctive devices such as directional atherectomy, rotational atherectomy, excimer laser and cutting balloons for the purposes of debulking or modifying plaque at ostial sites, with varying degrees of success. With the introduction of bare metal stents and drug eluting stents, the restenosis rates and complication rates reduced as compared to balloon angioplasty but the outcomes of placement of DES at ostium still remain inferior to non-ostial lesions.24, 25
  • Iatrogenic aortocoronary dissection complicating coronary interventions is extremely rare and a few cases have been reported. The incidence of this complication is approximately 0.02% for diagnostic coronary angiography and 0.02-0.83% for PCI procedures.26
  • The rapid propagation of aortocoronary dissection may become life threatening and should be recognized immediately. Most reported iatrogenic aortocoronary dissections have been related to procedures in the RCA, especially during PCI for chronic total occlusions.27
  • These are some of the unique complications of ostial PCI:
    • The calcified ostium may lead to incomplete stent expansion and predispose to restenosis or stent thrombosis
    • Direct contact between the guiding catheter and the proximal edge stent struts may lead to longitudinal stent deformation
    • Trauma to the ostium from the guide catheter or during balloon inflation may result in dissection of the coronary artery and aortic root
    • There are higher chances of stent misplacement and excessive stent protrusion

Prevention and Treatment of Ostial PCI complications

Guide catheter-induced dissection/occlusion of flow
  • Selection of less aggressive guide catheters
  • Cautious catheter manipulation
  • Rapid wiring and pre-loading coronary wire before guide engagement
  • Once wire down the vessel try and disengage the guide from ostium to avoid ostial occlusion in case of tight ostial lesions
  • Anticlockwise rotation to disengage catheter from RCA ostium
  • Aorto-coronary dissection can be successfully managed by stenting of the entry point of the coronary dissection if the dissection extends 40 mm from the ostium or in cases of occlusion of the dissected vessel with cessation of antegrade flow that cannot be restored percutaneously, and if the extension of the dissection is up to the descending aorta28

Misplacement of the stent
  • Optimal angiographic views with proximal positioning of stent marker
  • The stent should be positioned protruding into the aorta by 1–2 mm to prevent recoil of the lesion at the stent edge
  • Avoid using very short (<12 mm) stents to ensure adequate anchoring of the stent and to provide adequate lesion coverage distally
  • Use the presence of ostial calcium to assist with stent positioning
  • Stent pull-back technique for non aorto-ostial sites29

Inadequate stent expansion
  • Make sure to prepare lesion adequately, use of cutting balloon, rotational atherectomy is highly recommended
  • Routine use of high pressure non-compliant balloon for post dilation
  • Use of IVUS to assess for stent sizing and expansion is recommended

Side branch closure
  • Accurate stent positioning crucial
  • If risk of side branch closure high (calcified, pre-existing lesion >50%, tortuous. lesion length >10mm) consider wire protection or upfront dedicated 2 stent bifurcation stenting if side branch size >2.5mm30
  • Kissing PTCA to side branch if flow compromised
  • IC vasodilators to exclude spasm

Longitudinal stent deformation (LSD)
  • Avoid deep intubation with guiding catheters or extension systems through already stented segment
  • If resistance to passage of a secondary device in the stent do not push hard
  • When LSD is suspected, radiographic assessment of the stented segment, preferably with StentBoost (Philips, Andover, Massachusetts) or an equivalent image-enhancement program, should be done
  • Confirm wire position and use a small compliant balloon followed by a high-pressure noncompliant balloon aiming to ensure adequate expansion of deformed stent struts and their apposition to coronary arterial. If LSD still persists, another stent can be used
  • IVUS is strongly encouraged, although it is advisable to proceed to intracoronary imaging once LSD has been treated to avoid further potential deformation

Excessive proximal stent protrusion
  • Adequate lesion preparation to prevent stent crossing failure
  • Optimal angiographic views to accurately position the proximal stent marker
  • Since the guide is disengaged during stent positioning, it may be difficult to visualize the ostia. If possible, use the presence of ostial calcium to assist with stent positioning
  • Stent pull-back technique for non aorto-ostial sites29
  • Use of buddy wire for positioning marker in side branch or aorta
  • After stent deployment, perform light “flaring” of the ostium of the stent
  • Use of Flash Ostial Balloon may be used for flaring of ostial stent31

Edge dissection or perforation
  • Adequate lesion preparation is key
  • Avoid stent edge deployment at site of significant plaque (Imaging helpful)
  • In case of dissection or perforation use prolonged balloon inflation +/- another stent deployment


References

  1. Francesco Giannini, Luciano Candilio, Satoru Mitomo, Neil Ruparelia, Alaide Chieffo, Luca Baldetti, Francesco Ponticelli, Azeem Latib, Antonio Colombo. Practical Approach to the Management of Complications During Percutaneous Coronary Intervention. J Am Coll Cardiol Intv. 2018 Sep, 11 (18) 1797-1810.
  1. Brilakis E.S., Best P.J.M., Elesber A.A., et al. (2005) Incidence, retrieval methods, and outcomes of stent loss during percutaneous coronary intervention. Catheter Cardiovasc Interv 65:333–340.
  2. Bolte J., Neumann U., Pfafferott C., et al. (2001) Incidence, management, and outcome of stent loss during intracoronary stenting. Am J Cardiol 88:565–567.
  3. Kozman H., Wiseman A.H., Cook J.R. (2001) Long-term outcome following coronary stent embolization or misdeployment. Am J Cardiol 88:630–634.
  1. Tan KH, Sulke N, Taub N, Sowton E. Percutaneous transluminal coronary angioplasty of aorta ostial, non-aorta ostial, and branch ostial stenoses: acute and long-term outcome. Eur Heart J 1995;16:631-9.
  2. Mavromatis K, Ghazzal Z, Veledar E, Diamandopoulos L, Weintraub WS, Douglas JS, Kalynych AM. Comparison of outcomes of percutaneous coronary intervention of ostial versus nonostial narrowing of the major epicardial coronary arteries. Am J Cardiol 2004;94:583-7.
  3. Jokhi P, Curzen N. Percutaneous coronary intervention of ostial lesions. EuroIntervention 2009;5:511-514.
  4. Rocha-Singh K, Morris N, Wong SC, Schatz RA, Teirstein PS. Coronary stenting for treatment of ostial stenoses of native coronary arteries or aortocoronary saphenous venous grafts. Am J Cardiol 1995;75:26-9.
  5. Iakovou I, Ge L, Michev I, Sangiorgi GM, Montorfano M, Airoldi F, Chieffo A, Stankovic G, Vitrella G, Carlino M, Corvaja N, Briguori C, Colombo A. Clinical and angiographic outcome after sirolimus-eluting stent implantation in aorto-ostial lesions. J Am Coll Cardiol 2004;44:967-71.
  6. Dunning DW, Kahn JK, Hawkins ET, O'Neill WW. Iatrogenic coronary artery dissections extending into and involving the aortic root. Catheter Cardiovasc Interv. 2000;51(4):387–393.
  7. Boukhris M, Tomasello SD, Marzà F, Azzarelli S, Galassi AR. Iatrogenic aortic dissection complicating percutaneous coronary intervention for chronic total occlusion. Can J Cardiol. 2015;31(3):320–327.
  8. Wykrzykowska JJ, Ligthart J, Lopez NG, Schultz C, Garcia-Garcia H, Serruys PW. How should I treat an iatrogenic aortic dissection as a complication of complex PCI? EuroIntervention. 2012;7(9):1111–1117.
  9. Kini AS, Moreno PR, Steinheimer AM, et al. Effectiveness of the stent pull-back technique for nonaorto ostial coronary narrowings. Am J Cardiol. 2005;96(8):1123-1128. doi:10.1016/ j.amjcard.2005.06.043.
  10. Sharma SK, Sweeny J, Kini AS. Coronary bifurcation lesions: a current update. Cardiol Clin. 2010;28(1):55‐70. doi:10.1016/ j.ccl.2009.10.001.
  11. Riley R, Lombardi B. Solving the dilemma of ostial stenting: a case series illustrating the flash ostial system.Cardiol Cardiovascmed. 2017;1(1):64-71.

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