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Complications – how to manage
EuroCTO Club
October 1, 2016
Emmanouil S. Brilakis, MD, PhD
Minneapolis Heart Institute
Adj. Professor of Medicine, UT Southwestern
1.30-1.45 pm
ES Brilakis: Disclosures
Consulting/speaker honoraria: Abbott
Vascular, Asahi, Cardinal Health, CTI,
Elsevier, GE Healthcare, St Jude
Medical
Employment (spouse): Medtronic
Grants: InfraRedx, Boston Scientific
VA - I01-CX000787-01
VA CSP#571 – DIVA
CORONARY
1. Vessel closes
• Dissection
• Embolization
• Spasm
• Pseudolesion
2. Vessel Leaks
• Perforation
3. “Wrong place”
• Equipment loss
PCI complications: a classification
HEART
1. MI
2. Arrhythmia -
arrest
3. Tamponade
OTHER
1. Access
2. Thromboembolic
3. Contrast
• Nephropathy
• Allergies
4. Radiation
CORONARY
1. Vessel closes
• Dissection
• Embolization
• Spasm
• Pseudolesion
2. Vessel Leaks
• Perforation
3. “Wrong place”
• Equipment loss
PCI complications: a classification
HEART
1. MI
2. Arrhythmia -
arrest
3. Tamponade
OTHER
1. Access
2. Thromboembolic
3. Contrast
• Nephropathy
• Allergies
4. Radiation
RCA CTO
Dual
injection
Crossing
confirmation
True to true
crossing
into aorta
Viper snared
and
externalized
Chest pain
and
hypotension
Lesson
Donor vessel
occlusion can be a
lethal event!
LAD wiring
and balloon
Stent placed in
LAD over
retrograde
guidewire
(microcatheter
removed)
Proximal
RCA stent
LAD?
Retrograde
microcatheter
to free wire
Retrograde
wire out!
Final LAD
Septal
hematoma
Procedure time: 7h 20min
Fluroscopy time: 118 min
AK dose: 11.2 Gray
Contrast: 1,430 ml
CORONARY
1. Vessel closes
• Dissection
• Embolization
• Spasm
• Pseudolesion
2. Vessel Leaks
• Perforation
3. “Wrong place”
• Equipment loss
PCI complications: a classification
HEART
1. MI
2. Arrhythmia -
arrest
3. Tamponade
OTHER
1. Access
2. Thromboembolic
3. Contrast
• Nephropathy
• Allergies
4. Radiation
Types of coronary perforation
Main Vessel
perforation
Distal Wire
perforation
Collateral
perforation
LAD CTO
AWE
Fielder XT
Wiring
confirmed
Predilation
– balloon
rupture
Lesson
Balloon rupture can
cause perforation
NOW
WHAT??
Perforation management
1. Inflate balloon to occlude vessel
2. Stat echo – pericardiocentesis
Stop
bleeding
Perforation management
1. Inflate balloon to occlude vessel
2. Stat echo – pericardiocentesis
Autotransfuse
Type + cross
Call surgeons
Perforation management
yes
1. Inflate balloon to occlude vessel
Monitor pt Treat the cause
no
Persistent extravasation?
2. Stat echo – pericardiocentesis
Autotransfuse
Type + cross
Call surgeons
Perforation management
yes
1. Inflate balloon to occlude vessel
Monitor pt
Large vessel
perforation
Contralateral access
Covered stent
Treat the cause
no
Persistent extravasation?
2. Stat echo – pericardiocentesis
Distal vessel wire
perforation
embolization or
suction
Autotransfuse
Type + cross
Call surgeons
Brilakis ES. Manual of coronary CTO interventions. Elsevier 2013
Large vessel perforation management 2
Brilakis ES. Manual of coronary CTO interventions. Elsevier 2013
Large vessel perforation management 3
Ping-pong
Lesson
Second guide can minimize
duration of pericardial
bleeding
Graftmaster Rx
• HDE - IRB approval needed
• 2.8 - 4.0 mm stents: 6 French guide
• 4.5 and 4.8 mm stents: 7 French guide
Papyrus
Unable to
deliver
2.80x19 mm
Graftmaster
6 Fr
Guideliner
Guideliner
and balloon
Covered
stent
through
Guideliner
Perforation
sealed
TTE
Lesson
With early treatment of perforation
tamponade can be avoided
After stents
ACT=227
Lesson
Bleeding can be
followed by thrombosis
Export
catheter
Final result
TTE at the end
1. Balloon rupture can be bad!
2. Large vessel perforation –
immediate sealing to prevent
tamponade
3. Ping-pong technique
4. Covered stents
5. Bleeding and thrombosis:
delicate balance
Conclusions
Perforation management
yes
1. Inflate balloon to occlude vessel
Monitor pt
Large vessel
perforation
Contralateral access
Covered stent
Treat the cause
no
Persistent extravasation?
2. Stat echo – pericardiocentesis
Reverse anticoagulation
Distal vessel wire
perforation
embolization or
suction
continued extravasation?
Autotransfuse
Type + cross
Call surgeons
Types of coronary perforation
Main Vessel
perforation
Distal Vessel
perforation
Collateral
perforation
RCA CTO
STAR
After
balloon
Different
view
Lesson:
Accept the facts –
FAST!
Lesson
Watch your wire!
Replace polymer
wires with
workhorse after
crossing
Perforation management
1. Inflate balloon to occlude vessel
2. Stat echo – pericardiocentesis
“Block and deliver”
Perforation management
yes
1. Inflate balloon to occlude vessel
Monitor pt
Large vessel
perforation
Contralateral access
Covered stent
Treat the cause
no
Persistent extravasation?
2. Stat echo – pericardiocentesis
Distal vessel wire
perforation
embolization or
suction
Autotransfuse
Type + cross
Call surgeons
Brilakis ES. Manual of coronary CTO interventions. Elsevier 2013
Distal vessel perforation management 1
Distal vessel perforation management 2
Brilakis ES. Manual of coronary CTO interventions. Elsevier 2013
Distal perforation treatment
1. Fat
2. Coil
3. Aspiration through microcatheter
4. Thrombus
5. Micro-beads
6. Thrombin
7. ??
A C
B D
Lesson
Fat floats!
Currently used coils in our lab
Axium – ev3 Azur – Terumo
Finecross 1.8 Fr Progreat 2.8 Fr
Block +
Deliver
Coil 1
Lesson:
Don’t push out coils
with the back end of
a wire!
Coil 2
Coil 3
Bleeding
continues
Bleeding
stopped
(finally…)
Perforation management
yes
1. Inflate balloon to occlude vessel
Monitor pt
Large vessel
perforation
Contralateral access
Covered stent
Treat the cause
no
Persistent extravasation?
2. Stat echo – pericardiocentesis
Reverse anticoagulation
Distal vessel wire
perforation
embolization or
suction
continued extravasation?
Autotransfuse
Type + cross
Call surgeons
Lesson:
Contrast echo to
ensure pericardial
bleeding has stopped
1. Block + Deliver technique for
distal vessel perforation
2. Contrast echo to ensure
pericardial bleeding has stopped
3. Know your coils!
Lessons
Wilson et al. CCI 2015;86:407–41
Wilson et al.
CCI 2015;86:407–41
Lesson
Perforation in the
post CABG patient
can be a lethal
complication – and
very hard to treat
1. Watch your wire!
2. Exchange polymer wires
3. Don’t ignore distal vessel perf
(tamponade can happen hours
later)
4. Prior CABG: perforation NOT
safe!
5. Block and deliver fat first
6. Know how to use coils
DISTAL WIRE PERFORATION: summary
Types of coronary perforation
Main Vessel
perforation
Distal Vessel
perforation
Collateral
perforation
Lesson
Epicardial collateral
perforation requires sealing
from both sides
CORONARY
1. Vessel closes
• Dissection
• Embolization
• Spasm
• Pseudolesion
2. Vessel Leaks
• Perforation
3. “Wrong place”
• Equipment loss
PCI complications: a classification
HEART
1. MI
2. Arrhythmia -
arrest
3. Tamponade
OTHER
1. Access
2. Thromboembolic
3. Contrast
• Nephropathy
• Allergies
4. Radiation
Mechanisms of stent loss
Brilakis, Garratt. Strategic Approach to coronary interventions 2005
RetrieveDo not
retrieve•Deploy
•Crush
“Attempts at removal may make things worse”
“Retrieval approaches require imagination, creativity, flexibility andexcellent visualization”
David R. Holmes, Jr, MD
Stent Loss
Stent retrieval: small balloon
technique
Brilakis, Garratt. Strategic Approach to coronary interventions 2005
Stent crushing
Brilakis, Garratt. Strategic Approach to coronary interventions 2005
Stent retrieval: loop snare
Brilakis, Garratt. Strategic Approach to coronary interventions 2005
Stent Loss 1
A
B
C
F
D E
Stent partially in left
main and partially
in aorta
Stent Loss 2
G H
I Successful
snaring
with
Ensnare
Stent
Loss 3
Conclusions
1. Complications happen!
• Learn how to detect and treat them
2. Perforation: inflate a balloon to stop
bleeding + pericardiocentesis if patient
hemodynamically unstable
3. Treat the cause
Large vessel perf: covered stent
Distal vessel perf: fat / coils
4. Remain calm – communicate with team
