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.     

Delayed coronary perforation four days after percutaneous coronary intervention with subsequent cardiac tamponade: A case report

Coronary artery perforation (CAP) is a rare but lethal complication of percutaneous coronary interventions (PCIs), and its incidence has been increasing with advances in PCI techniques. Delayed CAP presents a highly challenging complication, as it occurs 30 min−9 days after intervention, making subsequent diagnosis and treatment difficult. We present the case of a 63-year-old male patient who underwent PCI for an obtuse marginalis II because of posterior wall myocardial infarction. Following 4 days of uneventful postoperative stay, the patient developed angina pectoris and hypotension 4 h after reinitiation of anticoagulant therapy with edoxaban. Angiography revealed distal vessel perforation from a side branch of the obtuse marginalis II. The vessel was occluded using autologous fat embolization via a microcatheter, resulting in complete sealing of the perforation. After discharge, 4 weeks after the infarction, the patient started rehabilitation therapy. Distal vessel perforations are typically caused by wire damage. In our case, we also suspected distal wire perforation, which was initially not recognized possibly due to distal occlusion through the thrombotic material. The temporal correlation between the re-initiation of anticoagulant therapy and the occurrence of cardiac tamponade suggests that the thrombotic material was resolved due to the former. The management of delayed CAP does not differ from that of CAP; thus, this rare complication should be considered even days after PCI as it could prove lethal if not recognized early.     

Management of Coronary Artery Perforation

Coronary artery perforation (CAP) is a rare but potentially life-threatening complication of percutaneous coronary intervention (PCI), however if recognized and managed promptly, its adverse consequences can be minimized. Risk factors for CAP include the use of advanced PCI technique (such as atherectomy and chronic total occlusion interventions) and treatment of severely calcified lesions. There are 3 major types of CAP depending on location: (a) large vessel perforation, (b) distal vessel perforation, and (c) collateral perforation.Large vessel perforation is usually treated with implantation of a covered stent, whereas distal and collateral vessel perforations are usually treated with coil or fat embolization. In this article we provide a state-of-the-art overview of the contemporary management of CAP.     

Successful collapse vessel treatment with a syringe for thrombus-aspiration after the guidewire-induced coronary artery perforation

Coronary artery perforation is a rare however potentially life-threatening complication of percutaneous coronary intervention that could cause cardiac tamponade. It requires emergent surgery unless an appropriate procedure is performed immediately. In distal coronary artery perforations with guidewires, several procedures were reported to be effective in refractory cases after prolonged balloon inflation and reversal of heparin by protamine sulfate to induce hemostasis. We describe a case of successful collapse distal coronary artery treatment with a syringe for thrombus-aspiration without materials for an embolization after guidewire-induced coronary artery perforation.     

Coronary Artery Perforations in the Contemporary Interventional Era

Background: Coronary perforations represent a serious complication of percutaneous coronary intervention (PCI).
Methods: We performed a retrospective analysis of documented coronary perforations at Massachusetts General Hospital from 2000 to 2008. Medical records review and detailed angiographic analysis were performed in all patients.
Results: Sixty-eight cases of coronary perforation were identified from a total of 14,281 PCIs from March 2000 to March 2008 representing an overall incidence of 0.48%. The study cohort was predominantly male (61.8%), mean age 71±11 years with 78% representing acute cases (unstable angina: 36.8%, NSTEMI: 30.9%, STEMI: 10.3%). Coronary artery perforation occurred as a complication of wire manipulation in 45 patients (66.2%) with 88.9% of this group being hydrophilic wires, of coronary stenting in 11 (16.2%), of angioplasty alone in 6 (8.8%), and of rotational atherectomy in 8 (11.8%). The perforation was sealed with an angioplasty balloon alone in 16 patients (23.5%), and with stents in 14 patients (20.6%) (covered stents: 11.8% and noncovered stents: 8.8%). Emergency CABG was performed in 2 patients (2.9%). Five patients (7.4%) developed periprocedural MI. The in-hospital mortality rate was 5.9% in the study cohort.
Conclusion: Coronary artery perforation as a complication of PCI is still rare as demonstrated in our series with an incidence of 0.48%. The predominant cause of coronary perforations in the current era of PCI is wire injury.     

Successful closure of coronary artery perforation using non-conventional embolic material

Coronary perforation during percutaneous coronary interventions is a rare but dreadful complication. While coronary perforation involving large vessels are managed successfully by covered stents, small distal vessel perforation is usually managed by prolonged balloon inflation or embolization of gel foam/thrombogenic metallic coils. We describe a case, where perforation of a small ventricular branch of the right coronary artery was successfully occluded by packing it with pieces of thrombogenic floppy tips of used coronary angioplasty guidewires instead of conventional metallic coils.     

Retrograde balloon hemostasis

Despite improvements in current devices and techniques for complex chronic total occlusion (CTO) percutaneous coronary intervention (PCI), procedural complications, including coronary perforation, still occur and could be life-threatening. A patient with a history of multivessel coronary artery disease and a CTO of the right coronary artery (RCA) underwent successful retrograde crossing of an RCA CTO. After wiring the CTO body and lesion dilatation, a drug-eluting stent was implanted in the distal RCA toward the posterior descending artery. A large Ellis type III perforation occurred at the distal edge of the stent. Septal crossing with a balloon and tamponade of the perforation site through the retrograde collaterals followed, as the RCA was not suitable to accommodate easily both the covered stent and the balloon simultaneously. This case report presents a novel approach the “septal retrograde ping-pong” technique, which demonstrates successful treatment of coronary perforations by utilizing a retrograde approach through a septal collateral. This technique proves to be effective in situations where the conventional antegrade balloon or covered stent delivery methods are not feasible or unsuccessful. This innovative approach offers a promising alternative for managing challenging cases of coronary perforations, providing new insights and potential solutions for interventional cardiologists.     

Procedural Effectiveness With a Focused Force Scoring Angioplasty Catheter: Procedural and Clinical Outcomes From the Scoreflex NC Trial

BackgroundThe Scoreflex NC scoring angioplasty catheter is designed with a short rapid-exchange tip distal to a non-compliant, high-pressure balloon and an integral wire outside of the balloon, such that the guidewire and the integral wire act as scoring elements during balloon inflation. The external scoring elements enable a focal stress pattern facilitating expansion of resistant lesions at lower pressures using a focused force angioplasty effect.MethodsPatients undergoing elective percutaneous coronary intervention (PCI) were enrolled in a prospective, single-arm study conducted at 12 centers in the United States. The primary endpoint was device procedural success, defined as the composite of successful device delivery to the target lesion with balloon inflation and deflation; absence of vessel perforation, flow-limiting dissection or reduction in TIMI flow from baseline; and achievement of final TIMI 3 flow.ResultsAmong 200 patients (234 lesions), lesion complexities included: bifurcation disease (37.6%), moderate/severe calcification (36.6%), and total occlusions (5.0%). Successful delivery to the target lesion, inflation and removal of the balloon catheter was achieved in 95.5% of patients (191/200). Procedural success was achieved in 93.5% (187/200) of patients, and final TIMI 3 flow was observed in 99.0% of cases (198/200). No unanticipated device-related events occurred. In-hospital major adverse events were reported in 4.5% of patients (9/200), related to periprocedural myocardial infarction (8/200, 4.0%) and target lesion revascularization (1/200, 0.5%).ConclusionsAmong patients undergoing elective PCI and with varied lesion complexity, these results support the safety and effectiveness of a dilation strategy using the Scoreflex NC scoring catheter.     

Early and late clinical outcomes following coronary perforation in patients undergoing percutaneous coronary intervention.

Coronary perforation is a rare but serious complication that occurs during percutaneous coronary intervention (PCI). This study examines the frequency of coronary perforation during PCI, evaluates the management strategies used to treat perforations, and describes the long-term prognosis of patients who have developed coronary perforation during PCI. Coronary perforations were found in 69 (0.93%) of 7,443 consecutive PCI procedures, occurring more often after use of a new device (0.86%) than after use of balloon angioplasty (0.41%) (p<0.05). Coronary perforation was attributable solely to the coronary guidewire in 27 (0.36%) cases. Coronary perforations were divided into 2 types: (1) Those with epicardial staining without ajet of contrast extravasation (type I, n=51), and (2) those with a jet of contrast extravasation (type II, n= 18). Patients with type I and type II perforations were managed by observation only (35% and 0%, respectively), reversal of anticoagulation (57% and 94%), pericardiocentesis and drainage (27% and 61%), and prolonged perfusion balloon angioplasty (16% and 100%). Two patients with type II perforations required emergency coronary artery bypass surgery. There were no in-hospital deaths. Late pseudoaneurysms developed in 18 (28.6%) patients during the 13.4 +/- 11.3 months' follow-up period, and were more common in patients with type II perforations (72.2% vs 11.1% with type I perforations; p<0.001). During the follow-up period, no patient had evidence of coronary rupture. The results suggest that coronary perforation is uncommon after PCI, and can be managed without cardiac surgery in the majority of cases. Late pseudoaneurysms developed in some patients, particularly in patients with type II perforations, but there were no late consequences of coronary perforation after PCI.     

Successful treatment of distal coronary guidewire-induced perforation with balloon catheter delivery of intracoronary thrombin.

Distal coronary artery perforation with a coronary guidewire is a relatively rare but potentially fatal complication during PTCA. Historically, these types of perforations have been easy to control with reversal of heparin anticoagulation combined with prolonged distal balloon inflation. In the modern era, with widespread use of potent glycoprotein IIb/IIIa inhibitors, this type of distal wire perforation has become more difficult to manage and potentially lethal. In this article, we report two cases of guidewire-related distal coronary artery perforation, successfully treated using a new technique using localized, distal intracoronary thrombin injection. During prolonged low-pressure balloon inflation, a small dose of thrombin was injected just proximal to the wire perforation site via the lumen of a coronary balloon catheter. This approach appears to be a relatively rapid and effective way to control this troublesome complication.     

Use of “super‐glue” to seal a perforation during chronic total occlusion coronary intervention and the potential to “unglue” it

Coronary perforation remains a dreaded complication of chronic total occlusion (CTO) percutaneous coronary intervention (PCI). We present a case of successful CTO recanalization complicated by a perforation treated by n‐butyl‐cyanoacrylate (medical “super‐glue”). We also present an in vitro experiment showing that a glue plug in a plastic tube can acutely be passed by a low tip load guide wire and undergo balloon angioplasty recreating a lumen. These results suggest that n‐butyl‐cyanoacrylate glue may be an alternative for treating perforation during CTO PCI with the possibility of recanalizing the vessel through the glue plug at a later time.     

Use of a second buddy wire during percutaneous coronary interventions: a simple solution for some challenging situations

The buddy wire technique, i.e. the use of a second 0.014 inch guide wire placed alongside the one employed to advance balloons and stents inside the coronary artery during percutaneous coronary intervention (PCI), may help in a series of procedural challenges during PCI. Indeed, by improving both the stability of the guiding catheter and the support for balloon and stent, a buddy wire use is sometimes the simplest way to accomplish a successful procedure. In this paper, we discuss technical aspects of some specific circumstances frequently encountered during PCI, in which a buddy wire may be helpful. These include: 1) The reduction of balloon slippage during angioplasty for in-stent restenosis; 2) insufficient back-up of the guiding catheter; 3) stenting of lesions located in vessels with proximal tortuosities/angulations; 4) stenting of lesions distally located in the vessel; 5) facilitation in the positioning of distal protection devices; 6) stenting of a lesion distally located from a previously implanted stent or from a coronary segment with both calcification and sharp bend; 7) PCI on coronary arteries with anomalous origin. Because of its simplicity, low cost, and availability, the use of a buddy wire should be considered when dealing with the aforementioned conditions during PCI procedures.     

Clinical and angiographic outcome of patients with mild coronary lesions treated with balloon angioplasty or coronary stenting. Implications for mechanical plaque sealing.

AIMS: To investigate the clinical and angiographic outcome of patients with mild coronary lesions treated with balloon angioplasty or coronary stenting (coronary plaque sealing, i.e. dilatation of angiographically non-significant lesions) compared to moderate and severe stenoses. METHODS AND RESULTS: Patients with chronic stable angina and a single de novo lesion in a native coronary vessel scheduled to undergo percutaneous coronary intervention (PCI) were selected from 14 different studies. Off-line analysis of angiographic outcomes was assessed in all patients using identical and standardised methods of data acquisition, analysis and definitions. Clinical endpoints were adjudicated by independent clinical events committees. All quantitative coronary angiographic (QCA) analyses were performed in the same core laboratory. Stenosis severity prior to PCI was categorised into three groups: <50% diameter stenosis (DS), 50-99%DS and >99%DS pre. A total of 3812 patients were included in this study; 1484 patients (39%) were successfully treated with balloon angioplasty (BA) only and stented angioplasty was performed in 2328 patients (61%).One-year mortality and rate of non-fatal myocardial infarction (MI) (Kaplan-Meier) did not differ between BA and stented angioplasty for any of the stenosis severity categories. Following BA, the combined event rate (death and non-fatal MI) was 4.8, 4.6 and 0% in the <50, 50-99 and >99%DS categories, respectively. Following stented angioplasty, the combined event rate was 3.1, 4.4 and 4.8% in the same categories. The need for repeat revascularisation corrected for stenosis severity in the Cox proportional-hazards regression model was reduced by 20% after stented angioplasty (hazard ratio (HR) 0.80, 95%CI 0.69-0.93). CONCLUSION: The concept of plaque sealing is appealing from the theoretical point of view. However, with current technology, plaque sealing cannot prevent death and future non-fatal MIs in the long-term because 1-year event rates after PCI of non-significant stenoses remain unacceptably elevated when compared with the estimated 1-year probability of a non-fatal MI in lesions with a <50%DS. Moreover, major adverse cardiac events at 1-year after PCI are not directly related to the degree of pre-procedural stenosis severity.     

The changing pattern of coronary perforation during percutaneous coronary intervention in the new device era

We report the incidence, management and clinical outcome of coronary perforations in 39 of 12,658 patients (0.3%) undergoing percutaneous coronary intervention (PCI). Coronary perforation occurred more frequently with debulking techniques than with non-debulking (percutaneous transluminal coronary angioplasty and stent) techniques (1% versus 0.2%; p<0.001). There were 8 type I (20.5%), 15 type II (38.5%) and 16 type III (41%) perforations. Importantly, fifty-one percent of the coronary perforations were guide-wire related. Major adverse clinical outcomes occurred more frequently in patients who experienced type III perforations. Conventional strategies to treat perforations (i.e., prolonged balloon inflation and reverse of the anticoagulated state) were used. There was one death (2.6%), two emergency surgeries (5.2%) and no Q-wave myocardial infarctions. Pericardial effusion occurred in 18 of 39 patients (46.2%), with cardiac tamponade occurring in 7 patients. In the current device era, the incidence of coronary perforation remains low; it occurs more frequently with debulking devices and is often a consequence of guidewire injury. Its outcome is not affected with the use of IIb/IIIa antagonists. Treatment of coronary perforation requires early detection, angiographic classification, immediate occlusion of coronary vessel extravasation and relief of hemodynamic compromise, reversal of heparin anticoagulation, platelet transfusion in those patients treated with abciximab and cover stents.     

Covered stent implantation through a single 8‐french guide catheter for the management of a distal coronary perforation

Distal coronary perforation can cause early or late tamponade and is usually treated with fat or coil embolization. An alternative treatment strategy is occlusion of the ostium of the perforated vessel via implantation of a covered stent in the main vessel, which is typically achieved using the ping‐pong guide catheter technique. In this technique, a balloon is inflated over one guide catheter to stop pericardial bleeding and a covered stent is delivered through a second guide catheter due to inability to fit both a balloon and a covered stent through a single guide catheter. With development of lower profile rapid exchange covered stents, a single guide catheter can be used to both occlude the target vessel and deliver the covered stent. We describe a case of distal vessel perforation in which a balloon was inflated to stop pericardial bleeding, followed by delivery of a covered stent (Graftmaster, Abbott Vascular) through a single 8‐Fr guide catheter. This “block and deliver” technique represents a novel paradigm for treating coronary perforations through a single guide catheter, obviating the need for the ping‐pong guide catheter technique. © 2017 Wiley Periodicals, Inc.     

Intracoronary Autologous Blood to Seal a Coronary Perforation

BACKGROUND: Coronary artery perforation is a rare but serious complication of percutaneous coronary interventions. CASE REPORT: We report on the treatment of a coronary perforation during percutaneous transluminal coronary angioplasty (PTCA) of the left anterior descending (LAD) coronary artery in a patient suffering from post infarction angina complicated by cardiogenic shock. The perforation was treated successfully with intracoronary administration of the patient's own blood. CONCLUSION: This new technique may be used as adjunctive therapy to prolonged balloon inflation, coronary stenting, coronary microcoil and gelfoam embolization in the treatment of severe and hemodynamically compromising perforations.     

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.

     

Recanalization of chronic total peripheral arterial occlusions using optical coherent reflectometry with guided radiofrequency energy: a single center experience.

BACKGROUND: A forward-looking, fiberoptic guided device (Safe-Cross System, Intraluminal Therapeutics, Carlsbad, CA) has been used with guided radiofrequency energy to open chronic total occlusions (CTOs). This report describes the use of optical coherent reflectometry (OCR) system to assess safety and efficacy of opening CTOs in native peripheral arteries in the lower extremities: iliac, femoral, and popliteal. METHODS: 18 CTOs in native peripheral arteries in 17 patients were treated with OCR after failed attempts with conventional wires (minimum 10 min of fluoroscopic time). When the CTO was crossed, routine angioplasty with or without stent was performed. Efficacy was defined as achievement of distal lumen position. Safety was defined as device success without perforation, dissection (> or =Grade C), or distal embolization. The mean patient age was 72 years with 8 females and 10 males. Lesion characteristics included a mean vessel diameter of 5.8 mm and a mean lesion length of 22.4 cm. Ankle-brachial indices was < or =0.8 in all patients. RESULTS: The OCR system was successful in crossing 100% of the CTOs in patients that failed conventional wire crossing, whereas clinical success occurred in 94% of these patients. Complications consisted of a single dissection > or =Grade C. No perforations or distal embolization occurred. CONCLUSIONS: The Safe-Cross OCR System is both efficacious and safe in the treatment of CTOs that failed crossing with conventional wires and indirect visualization of the intraluminal position by using OCR technology appears to minimize vessel trauma, dissection, perforation, and distal embolization.     

A novel minimal-invasive model of chronic myocardial infarction in swine

BACKGROUND: Most animal studies on myocardial infarction (MI) have used open-chest models with direct surgical coronary artery ligation, which imply local as well as generalized side effects of major surgery. Some closed-chest models of MI have been established, mainly using catheterization techniques with coronary artery embolization, balloon occlusion, and intracoronary injection of thrombogenic agents. The aim of this study was to develop a closed-chest technique of chronic coronary artery occlusion at a selected location with subsequent thrombus formation without use of balloon inflation or thrombotic chemical agents. METHODS AND RESULTS: A coronary angiography via the carotid artery was performed using a 7 F guiding catheter in 21 pigs. After insertion of a percutaneous transluminal coronary angioplasty (PTCA) guide wire into the distal coronary artery, a vessel-size adapted flexible foreign body comprising an open-cell sponge was advanced into the coronary artery via the guide wire by a non-inflated PTCA balloon. Five min after removal of the guide wire and the balloon catheter, total coronary artery occlusion was documented by angiography. Retrograde thrombosis of the coronary artery occurred in three animals. After one week, total vessel occlusion at the previously selected location was visualized by coronary angiography in animals that had survived. Macroscopic analysis demonstrated the foreign body with subsequent thrombus formation in the coronary artery and distal MI. Post-mortem histological analysis revealed myocardial necrosis and granulocyte infiltration at the margin of the infarction, without damage to remote myocardium. CONCLUSIONS: This new easy-to-perform closed-chest technique provides reproducible chronic coronary artery occlusion at a selected location with subsequent MI. It avoids major surgery and thoracotomy and does not require balloon inflation or intracoronary injection of thrombotic or chemical agents.     

The Effects of Novel,Bioresorbable Scaffolds on Coronary Vascular Pathophysiology

Percutaneous coronary intervention (PCI) has rapidly evolved over the past 30 years as technology has sought to improve clinical outcomes by addressing pathophysiologic complications arising from the intervention. Stents were designed to resolve the drawbacks of balloon angioplasty by providing radial support to prevent vessel recoil, by sealing coronary dissections, and by preventing abrupt vessel closure. The conceptualization of an ideal drug-eluting fully bioresorbable scaffold (BRS), whether metallic or polymeric, would theoretically address the adverse aspects of permanent metallic stents. In this review of the literature, we will discuss the impact these novel fully BRS platforms have on vascular pathophysiology following PCI.