Successful management of a distal vessel perforation through a single 8‐French guide catheter: Combining balloon inflation for bleeding control with coil embolization

Coronary perforation is an infrequent, but serious complication of percutaneous coronary intervention (PCI), and is more likely to occur with complex (such as chronic total occlusion) PCI and use of atheroablative devices. For main vessel perforations, the “dual catheter” technique is usually employed in which a balloon is delivered over the first guide catheter to stop bleeding, whereas the covered stent is delivered through a second guide catheter. This is required because the large profile of the currently commercially available covered stents precludes fitting within even an 8‐French guide together with a balloon. However, coil embolization for distal artery wire perforation and collateral vessel perforation can be achieved through a microcatheter that can fit along with a balloon within an 8‐French guide catheter, obviating the need for a second guide catheter. We describe a case in which a distal artery wire perforation was successfully treated using a single 8‐French guide catheter. © 2015 Wiley Periodicals, Inc.     

An alternative treatment strategy for large vessel coronary perforations

The standard treatment for large vessel coronary perforations is implantation of a covered stent. Antegrade attempts for crossing a right coronary artery chronic total occlusion resulted in guidewire and microcatheter exit with pericardial bleeding. A balloon was inflated proximal to the perforation site to achieve temporary hemostasis. Retrograde crossing of the chronic total occlusion was achieved through an epicardial collateral using the reverse controlled antegrade and retrograde tracking technique. Stent implantation resulted in hemostasis, likely due to creation of a subintimal flap that sealed the perforation site. If technically feasible, subintimal recanalization can be an alternative treatment strategy for coronary perforations occurring during chronic total occlusion percutaneous coronary intervention.     

Modified dual guide catheter (“ping‐pong”) technique to treat left internal mammary artery graft perforation

Perforation of a left internal mammary artery (LIMA) graft during percutaneous coronary intervention is a rare event. We report a case of mid‐LIMA perforation treated by a polytetrafluoroethylene‐covered stent using a modification of the dual catheter (“ping pong”) technique. We propose that use of this modification when possible will further improve safety of treating a perforation. © 2014 Wiley Periodicals, Inc.     

Deep intubation of 8 Fr guiding catheter to deliver coronary stent graft to seal coronary perforation: a case report.

Coronary perforation is an uncommon complication of angioplasty and is a challenging situation to manage. We describe a case of complex multivessel coronary angioplasty complicated by coronary perforation following balloon rupture that was successfully managed with a coronary stent graft. Delivery of the stent graft to the site of vessel rupture required deep intubation of an 8 Fr guiding catheter over the shaft of an inflated balloon. In addition to the availability of covered stents, it is essential to be familiar with various skills necessary to deploy these stents. Cathet Cardiovasc Intervent 2001;54:59-62.     

Closure of guide wire-induced coronary artery perforation with a two-component fibrin glue.

Perforation or rupture of a coronary artery with subsequent pericardial effusion and cardiac tamponade is a potentially life-threatening complication of percutaneous coronary intervention (PCI). Several emergency treatment strategies exist to close the perforation including reversal of anticoagulation, prolonged balloon inflation, implantation of stent grafts, local injection of thrombogenic molecules, placement of microcoils, or open heart surgery. Here we report on a 66-year-old patient who underwent urgent PCI for acute stent thrombosis in the proximal LAD. The artery was reopened, a new stent implanted successfully, and a GPIIb/IIIa-antagonist was given. Shortly thereafter the patient suffered from cardiac tamponade requiring pericardiocentesis and pericardial drainage. The coronary angiogram indicated a severe guide wire-induced perforation and pericardial effusion originating from a distal diagonal branch segment. Prolonged balloon inflation did not stop the leakage. Therefore the monorail balloon was exchanged for an over-the-wire balloon. A two-component commercial fibrin glue consisting of fibrinogen and thrombin was rapidly but separately injected through the wire channel of the balloon into the distal segment of the diagonal branch. The coronary leak was successfully closed and the patient recovered quickly. In comparison with the previously reported cases of thrombin injection important differences should be noticed: (1) a two-component hemostatic seal was used without reversal of anticoagulation, (2) rapid injection instead of prolonged infusion of the hemostatic drugs was performed, and (3) the rescue technique was applied in a cath lab that routinely uses monorail catheter systems. Therefore we consider this a novel and effective approach for closure of coronary ruptures.     

Novel approach to coronary artery perforation repair

Coronary artery perforation (CAP) during percutaneous coronary intervention is a rare but serious complication. Treatment options of CAP include prolonged balloon inflation, covered stent, and coil embolization. Although most cases of CAP can be treated with prolonged balloon inflation, some cases, especially Ellis grade III CAP require covered stents or coiling. Covered stents may require a large bore guide catheter and have a high rate of restenosis, which can be a limiting factor in patients with severe peripheral arterial disease. Coil embolization is generally used in distal CAP because coiling in the proximal vessels results in a large territory of infarction. We present a case of an Ellis grade III CAP during rotational atherectomy successfully treated with a novel coiling technique whereby the thrombogenic coil extends through the perforation outside of the vessel, and the intraarterial portion of the coil is excluded from the lumen by drug‐eluting stent placement over the proximal portion of the coil.     

Radial artery perforation after coronary intervention: Is there a role for covered coronary stent?

We report a case of right radial artery perforation observed after successful stenting of left anterior descending artery through right radial access. This was noticed immediately after completion of the procedure, when the patient described right forearm pain and we noticed swelling of the right forearm. She was treated by a prolonged guiding catheter positioning proximal to the perforated segment, external compression by sphygmomanometer cuff followed by prolonged balloon inflation across the perforation. All these measures failed to stop the bleeding. Complete reconstruction of the perforation was achieved by PTFE covered coronary stent. To our knowledge, this is the first case to be managed utilizing this approach. © 2011 Wiley‐Liss, Inc.     

Coronary and peripheral stenting in aorto‐ostial protruding stents: The balloon assisted access to protruding stent technique

Treatment of aorto‐ostial in‐stent restenosis lesions represents a challenge for interventional cardiologists. Excessive protrusion of the stent into the aorta may lead to multiple technical problems, such as difficult catheter reengagement of the vessel ostium or inability to re‐wire through the stent lumen in repeat interventions. We describe a balloon assisted access to protruding stent technique in cases where conventional coaxial engagement of an aorto‐ostial protruding stent with the guide catheter or passage of the guide wire through the true lumen is not feasible. This technique is applicable both in coronary and peripheral arteries. © 2015 Wiley Periodicals, Inc.     

应用子母导管介入治疗复杂冠状动脉病变

目的:复杂冠状动脉病变（慢性闭塞性病变、严重迂曲病变、弥漫钙化）的介入治疗往往需要指引导管提供较强支撑力,单纯指引导管自身能提供的支撑力常常不够。本研究旨在初步探索子母导管系统在复杂冠状动脉病变介入治疗中需要强支撑力时应用的有效性与安全性。方法: 选择泰尔茂公司的Heartrail子母导管系统,系由一根5F的子指引导管和一根6F或7F的母指引导管构成。5F Heartrail子指引导管为直头指引导管,其内径为0059 in（1 in=254 mm）,长度为120 cm,比母指引导管长20 cm。使用方法是,母指引导管到位后,送入经皮腔内冠状动脉成形术（PTCA）导丝至冠状动脉内,沿PTCA导丝送入子导管至母导管远段,但不伸出远端,送入PTCA球囊至冠状动脉内,沿球囊导管推送子母导管进入冠状动脉内,根据需要提供的支撑力决定子母导管伸出指引导管的长度。结果: 自2008年6月~2010年12月共选择常规方法导丝、球囊或支架不能通过的复杂冠脉病变共26例（左前降支5例,左回旋支6例,右冠状动脉15例）,其中慢性闭塞性病变6例（23%）,血管迂曲15例（58%）,近段血管有支架植入10例（38%）,钙化病变15例（58%）,其中24例成功完成支架植入,成功率为92%,2例失败,均为球囊不能通过病变处,术中发生空气栓塞2例（8%）,经冠脉注射动脉血后血流通畅,术中无血管夹层及冠脉穿孔等并发症。随访6个月无死亡、再发心梗等心脏事件。结论: 子母导管系统应用于常规方法不能成功的冠脉复杂病变可增加支撑力,有助于远端支架植入,应用有效且安全,但术中需注意空气栓塞的发生。     

Bailout polytetrafluoroethylene‐covered stent implantation for left main bifurcation perforation using the kissing stent technique

Coronary artery perforation during percutaneous coronary intervention is a rare, but potentially lethal complication. Immediate balloon expansion at the perforation site can halt the bleeding. Implantation of a coronary polytetrafluoroethylene (PTFE)‐covered stent enables the efficient endovascular repair of a coronary artery perforation. However, if the perforation occurs at a bifurcation, a PTFE‐covered stent may jail the side branch. We report a difficult case of blowout coronary perforation (Ellis type III) at a left main coronary artery bifurcation, which was successfully sealed with a PTFE‐covered stent without interference with the side branch coronary artery circulation. This new strategy might represent a useful salvage option for some patients with a coronary bifurcation perforation. © 2017 Wiley Periodicals, Inc.     

Long‐term outcomes of intraoperative pulmonary artery stent placement for congenital heart disease

We report a novel technique for performing retrograde interventions on a coronary chronic total occlusion through an ipsilateral collateral. Two guiding catheters are used to engage the target coronary artery, one to advance to the retrograde guidewire and the other to externalize the retrograde guidewire and antegrade wiring. Engagement of the target coronary artery is alternating between the antegrade and the retrograde guide catheter in a “ping‐pong” fashion, enabling lesion crossing and equipment delivery. © 2011 Wiley‐Liss, Inc.     

Guidewire‐Induced coronary perforation successfully treated with subcutaneous fat embolisation: A simple technique available to all

A 62‐year‐old man presented with an anterior ST elevation myocardial infarction and underwent primary percutaneous coronary intervention to an occluded diagonal artery. Following stenting, a type III distal guidewire‐induced coronary perforation of the diagonal branch was recognized with extravasation of contrast into the pericardial space. Prolonged balloon inflations proximal to the site of the perforation were unsuccessful. Subcutaneous fat was therefore harvested from the patients upper thigh under local anesthetic and embolized through an Export catheter into the distal diagonal vessel, resulting in the immediate cessation of leak through the site of perforation. We discuss the technical aspects of this technique as well as alternative methods of distal embolization and the potential complications that must be considered. © 2015 Wiley Periodicals, Inc.     

Balloon crush: treatment of bifurcation lesions using the crush stenting technique as adapted for transradial approach of percutaneous coronary intervention.

The recent advent of drug-eluting stents has allowed the crush stenting technique to be adopted, thus simplifying the treatment of bifurcation coronary artery lesions. However, this can only be achieved in 7 Fr or greater guiding catheters, hence precluding most transradial percutaneous coronary interventions that are usually undertaken using 6 Fr or less guiding catheters. We assessed the feasibility of balloon stent crush as a stepwise procedure in achieving bifurcation crush stenting in 6 Fr transradial percutaneous coronary interventions. Since it is not possible to place two stents through a 6 Fr guiding catheter, we have adapted the crush stenting technique by initially placing a stent in the side branch and a balloon in the main vessel. The side branch stent is then deployed against the main vessel balloon that is later inflated, crushing the side branch stent within the main vessel. The main vessel is then stented and the side branch recrossed for kissing inflations. Seven patients (five males; age range, 47-78 years) with bifurcation lesions were treated using the above-described technique without major complications. Balloon crush of the side branch stent were successfully achieved in all cases without balloon trapping. In six cases where side branch recrossing was attempted, all were successful and kissing balloon inflations were undertaken in five cases. We have demonstrated that the modified crush stenting technique is feasible and can be safely adapted for use in a 6 Fr transradial percutaneous coronary intervention approach.     

Advances in the treatment of coronary perforations

• Coronary artery perforation is an infrequent, but potentially life‐threatening complication of percutaneous coronary intervention. There are four types of coronary perforation: (a) large vessel; (b) distal vessel; (c) septal collateral; and (d) epicardial collateral perforation.
• Implantation of a covered stent is the cornerstone of large vessel perforation treatment and can be used in some distal vessel perforations, when embolization is not feasible. Until now the only available covered stent in the US was the Graftmaster stent (two bare metal stents with a PTFE membrane in‐between them), that has high profile and is challenging to deliver and expand. Use of the Graftmaster has been associated with high rates of in‐stent restenosis and stent thrombosis.
• Availability of more deliverable covered stents, such as the BeGraft (Bentley InnoMed GmbH, Hechingen, Germany) and PK Papyrus (BIotronik, Lake Oswego, Oregon, that recently received FDA approval) will greatly facilitate treatment of large vessel coronary perforations.

     

Dual catheter technique for the treatment of severe coronary artery perforations

Objectives : To evaluate the outcome of patients with coronary perforations who were treated with the dual catheter approach. Background : Coronary artery perforation is a grave complication of percutaneous coronary intervention (PCI) with high mortality and morbidity. Treating a coronary artery perforation with two catheters through dual access enables a rapid delivery of covered stent or coils to the vessel, without losing control of the perforation site. Methods : We retrospectively reviewed all patients who had a severe coronary perforation during a PCI in our center, and compared outcomes of patients treated with the dual versus the traditional single guiding catheter approach. Results : Between April 2004 and October 2008, 13,466 PCI's were performed in Columbia University – New York Presbyterian Medical Center. There were 33 documented cases of coronary perforations during that period of time (0.245%), among these, 26 were angiographically severe (Ellis type 2 or 3 perforations). Eleven patients were treated acutely with a dual catheter technique whereas the other fifteen patients were treated using a single guiding catheter. In the dual catheter group one patient expired after emergent CABG (9.1%), and four patients underwent emergent paricardiocentesis (36.4%). In patients treated with single catheter, there were three deaths (20%), two surgical explorations (13.3%), eight emergent pericardiocenthesis (53.3%), and one event of severe anoxic brain damage (6.7%). Conclusion : The dual catheter technique is a relatively safe and reproducible approach to treat a PCI induced severe coronary artery perforation, and may improve outcome compared to historical series. © 2010 Wiley‐Liss, Inc.     

The draw-back stent deployment technique: a strategy for the treatment of coronary branch ostial lesions

Isolated ostial lesions in the coronary tree are not uncommon; the percutaneous coronary intervention (PCI) of choice is stent implantation. This report describes a simple technique for accurate stent deployment to effectively treat such lesions without visible encroachment on the main vessel lumen. The stent is advanced distally into the sidebranch. Using a separate system, a balloon is inflated as a fulcrum in the main vessel within the segment straddling the sidebranch. The sidebranch stent is withdrawn undeployed until it contacts the inflated main vessel balloon and is then deployed. This technique was attempted in 14 cases and successful in 13, with excellent stent deployment and lesion resolution attained in 12 cases. There were no instances of main vessel aggravation or procedural events. Subsequent target vessel revascularization has been necessary in two patients. This technique is a simple approach for managing these troublesome lesions.     

A novel mother and child technique with a 4F inner catheter based on proper alignment of both catheters

We occasionally encounter difficult cases of stent and balloon delivery to the distal lesion due to severe calcification or tortuosity of the proximal section. We describe a novel mother and child technique with a 4F inner catheter based on proper alignment of both catheters to deliver balloon, stent, and guide catheter to the distal lesion. © 2011 Wiley‐Liss, Inc.     

Limited balloon expansion through the struts of the Palmaz-Schatz and NIR stents compared with the Multi-Link stent

After placing a stent in the main vessel of a bifurcation lesion, it is sometimes necessary to perform further balloon inflation in order to treat an ostial lesion in a side branch. The stent struts may prevent full balloon expansion at the ostium of a side branch, resulting in residual ostial stenosis. The degree of completeness of balloon inflation may vary significantly depending on the stent design and structure. A model of a bifurcation lesion with an angle of 45 degrees was created from acrylic resin. The diameters of the main vessel and the side branch were both 3.5 mm. Deployment of the Palmaz-Schatz stent (n=5), NIR stent (n=5) or Multi-Link stent (n=5) was performed in the main vessel with a 3.5-mm balloon catheter inflated to 12 atm. A 3.5-mm balloon catheter was then inflated to 12 atm through the stent struts of the main vessel and into the ostium of the side branch. The degree of completeness of balloon inflation (% balloon expansion) was calculated as (smallest diameter of balloon catheter/reference diameter of balloon catheter) x 100%. The minimal lumen diameter (MLD) and cross-sectional area (CSA) at the ostium of the side branch created with the stent struts were also measured. Limited balloon expansion through the struts was observed with the Palmaz-Schatz stent and the NIR stent, but almost full balloon expansion was observed with the Multi-Link stent (% balloon expansion: Palmaz-Schatz stent 80%, NIR stent 60%, Multi-Link stent 94%, p<0.01). The MLD and CSA of the dilated struts, representing the ostium of the side branch, of the Palmaz-Schatz stent (2.2+/-0.1 mm, 4.5+/-0.3 mm2) and the NIR stent (1.8+/-0.1 mm, 3.1+/-0.3 mm2) were significantly smaller compared with those of the Multi-Link stent (3.0+/-0.2 mm, 8.4+/-0.6 mm2) (p<0.01). The struts of the Palmaz-Schatz stent and the NIR stent deployed in the main vessel of a bifurcation prevent full expansion of a balloon catheter inflated at the side branch ostium. In contrast, almost full balloon expansion through the struts of the Multi-Link stent is achieved.     

Treatment of rotablation‐induced ostial left circumflex perforation by papyrus covered stent and its fenestration to recover the left anterior descending artery during CHIP procedure

Coronary artery perforation is a rare complication of percutaneous coronary intervention (PCI). Covered stents have been successfully used in these situations. We report a case of ostial left circumflex (LCx) artery perforation during rotablation PCI of left main coronary artery (LMCA) and LCx artery. After failed attempts to balloon tamponade the perforation, a PK Papyrus covered stent was deployed from proximal LCx into LMCA. This resulted in acute exclusion of the left anterior descending (LAD) artery from coronary circulation. Using a dual lumen catheter, a stiff wire was advanced through the side port toward the occluded LAD to fenestrate the membrane of the covered stent. A series of balloons were used to dilate the fenestration in the covered stent to restore a normal flow into the LAD.     

Balloon sizing of pulmonary branch stenosis: a useful method to guide stent implantation

Among patients with congenital heart disease, pulmonary branch stenosis is a common indication for stent implantation. Selective calibrated angiography is the standard method of vessel sizing to guide angioplasty balloon and stent selection. Our aim was to compare vessel dimensions from standard calibrated selective angiography with those obtained using a compliant sizing balloon catheter. METHODS: 9 patients with 11 pulmonary branch stenoses underwent selective calibrated angiography. Amplatzer sizing balloon catheters positioned across the stenoses were inflated with dilute contrast agent. Digital angiograms were repeated in the same projections. Measurements from both methods were analyzed statistically. Minimum, maximum proximal and maximum distal vessel diameters were all significantly larger (p < 0.01) when measured by the sizing balloon method. Angioplasty balloons and stent diameters were chosen according to the sizing balloon measurements. In 7 of 8 stented lesions, larger angioplasty balloon diameters were selected for stent implantation than would have been chosen by standard angiography. Calibrated selective angiography may undersize vessel diameters. Use of a compliant sizing balloon appears to offer an accurate method to guide stent implantation in pulmonary branch stenosis.