ST-elevation myocardial infarction caused by coronary artery compression due to localized pericardial hematoma caused by coronary perforation

Coronary perforation is a rare but serious complication of percutaneous coronary intervention (PCI). We report a case of coronary perforation during PCI in a post cardiac surgery patient presenting as unusual ST-segment elevation myocardial infarction, secondary to compression of an epicardial artery by a localized hematoma, secondary to coronary perforation by the guidewire.     

Transradial retrograde approach rescuing iatrogenic long spiral dissection during chronic total occlusion intervention

Percutaneous coronary intervention (PCI) of chronic total occlusion (CTO) is one of the greatest challenges in coronary interventions. A retrograde approach via the collateral channel has been recently proposed to improve the success rate of PCI in CTO lesions of the coronary arteries. We describe an accidental complication encountered during transradial PCI to recanalize right coronary artery CTO in a patient with unstable angina. A long spiral dissection has been created by antegrade wiring and extended from the ostium all the way down to mid RCA segment. Subsequent attempts with antegrade wiring into the true lumen were unsuccessful. Ad‐hoc retrograde recanalization has been employed to rescue the vessel via septal collateral from left anterior descending artery. Retrograde wiring and dilatation were performed followed by successful antegrade wiring into the true lumen under IVUS guidance, which revealed significant intramural hematoma extending distally to the posterolateral branch. Bailout stenting was achieved with sealing of the multiple entry and exit sites created by the spiral dissection and complete coverage of the intramural hematoma. This report highlights the role of the retrograde approach as a rescue option in the setting of complicated antegrade approach and to improve the success rate of CTO‐PCI. Moreover, IVUS was a valuable tool to confirm the true lumen course of the successful wire and to guide the stenting procedure. © 2012 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.     

Treatment of chronic total occlusion by retrograde passage of stents through an epicardial collateral vessel

Chronic total occlusion (CTO) may occur in as many as 30–40% of patients with coronary artery disease. Retrograde revascularization through a collateral channel has been described earlier. We report the first case of retrograde passage of a stent through an epicardial collateral to revascularize a right coronary artery CTO. © 2008 Wiley‐Liss, Inc.     

Septum hematoma: a complication of retrograde wiring in chronic total occlusion

In spite of the remarkable technological innovation and improved outcomes with percutaneous coronary intervention (PCI), chronically total occlusion in coronary arteries (CTO) remains a formidable challenge for coronary interventionalist. Recently Japanese interventionists have proposed a retrograde wiring technique which provides another way to resolve such difficulties. The retrograde wire in the distal CTO vessel can then be used as a clear landmark in the distal true lumen, facilitating antegrade wiring and possibly increasing the success rate of CTO-PCI. Reported here is a patient who experienced retrograde wire technique but suffered from a complication with septum hematoma and myocardial infarction. The patient had a complete recovery of chest symptoms and resolution of septum hematoma in 1 month. Retrograde wire manipulation should be used as a last resort and via a large collateral vessel in the treatment of CTO.     

Percutaneous coronary intervention of a circumflex chronic total occlusion using an epicardial collateral retrograde approach.

Antegrade disobliteration of a chronic total coronary occlusion (CTO) may be technically difficult in spite of the use of customized equipment. Retrograde approaches via intramyocardial septal or bypass grafts have been described. We report a successful Percutaneous intervention of a proximal circumflex CTO using a retrograde approach via an epicardial collateral.     

Coronary septal collaterals as an access for the retrograde approach in the percutaneous treatment of coronary chronic total occlusions.

OBJECTIVES: To investigate the feasibility and safety of the percutaneous dilatation of coronary septal collaterals and to allow its use as an access for retrograde approach to percutaneous coronary intervention (PCI) of coronary chronic total occlusions (CTOs). BACKGROUND: Despite improvements in percutaneous techniques and materials, CTO recanalization success rate is still suboptimal. The retrograde approach allows to significantly increase this success rate. However, its application via a bypass graft or epicardial collateral can potentially result in severe complications. A safer retrograde access is desired and would allow broadening the application of the retrograde approach in the percutaneous treatment of CTOs. METHODS: After a failed antegrade CTO recanalization attempt, a retrograde approach via septal collaterals was tried in 21 patients (19 males, 2 females). The septal collateral was accessed via the contralateral patent coronary artery and was crossed with a hydrophilic floppy wire. After successful wire crossing of the septal collateral, sequential low pressure dilatation was performed with a 1.25 or 1.5 mm balloon to allow the delivery of a balloon catheter up to the distal CTO site. RESULTS: Successful wire crossing and balloon dilatation of septal collaterals was achieved in 19 cases and in 17 cases, respectively. Postdilatation septal collateral diameter increased significantly reaching a mean diameter of 1.46 +/- 0.38 mm. Retrograde CTO recanalization was successfully performed in 71% of the cases. No major complications occurred. CONCLUSIONS: Coronary septal collaterals can be used as an access for the retrograde approach in the percutaneous treatment of CTOs.     

Epicardial collateral channel for retrograded recanalization of chronic total occlusion percutaneous coronary intervention: Predictors of failure and procedural outcome

Objectives

This study set out to identify significant lesion features of chronic total occlusion (CTO) that predict successful retrograde recanalization via epicardial collateral channels (CCs).

Background

Epicardial CCs remain essential in retrograde percutaneous coronary intervention (PCI) of CTO. However, the unpredictability of success and occurrence of complications limit the application of epicardial CCs for retrograde PCI technique for CTO.

Methods

103 retro‐recanalization cases were analyzed using epicardial CCs with successful recanalization as an end point. Clinical and angiography data were collected.

Results

The total success rate was 76.3%. Independent predictors associated with technical success included CCs tortuosity, side branch at CCs tortuosity, inadequate CCs Size and inadequate CCs exit location. Assigning a score of one for each variable, four levels of difficulty were obtained and formed the EPI‐CTO score (Epicardial CTO). This score had significant predictive value for the likelihood of successful recanalization (AUC: 0.94, 95%CI: 0.89‐0.98). Coronary and CCs perforation occurred in 6 and 10 cases respectively. Four cases including two coronary and two CCs perforations had tamponade that needed pericardiocentesis.

Conclusions

Using epicardial CCs for retrograde approach of CTO PCI is effective. Complication rate was acceptable. We found four independent predictors relative to procedure success.     

Type A dissection of the ascending thoracic aorta during percutaneous coronary intervention

Retrograde dissection of the aorta is extremely rare during percutaneous coronary intervention (PCI), but is a recognized and potentially life-threatening complication. We describe a case in which retrograde dissection of the aorta, necessitating urgent surgical repair, occurred during an attempt to open a chronically occluded right coronary artery. Initially localized, the dissection extended during an attempt to seal the right coronary ostium. Our experience suggests that if localized aortic retrograde dissection occurs, the management will depend on the stability of the distal coronary vessel. If stable, a conservative approach may be preferable to an attempt to seal the dissection.     

经心外膜下侧支循环逆向介入治疗冠状动脉慢性完全闭塞病变

目的 探讨应用我国市场已有器械,经心外膜下侧支循环血管,对慢性完全闭塞(CTO)病变行逆向经皮冠状动脉介入治疗(PCI)的可行性.方法 5例CTO病变均在常规正向PCI失败后,行逆向PCI.将7 F强支撑逆向指引导管送至供体血管,超滑导丝通过心外膜下侧支循环血管到达CTO病变远端,在微导管支持下交换较硬的导丝,逆向通过CTO病变,逆向导丝继续进入6 F正向指引导管,并在正向指引导管内球囊扩张锚定.逆向扩张病变后,正向导丝通过病变,用常规PCI方法完成手术.其中应用捕获逆向导丝技术和反向CART技术各1例.结果 在逆向导丝通过侧支循环的路径中,经左前降支至右冠状动脉远端3例,经左回旋支至右冠状动脉1例,经钝缘支至左前降支1例.其中4例成功开通CTO病变,完成支架置入术.另外1例虽然导丝及微导管到达CTO病变远端,但无法逆向通过闭塞病变.所有患者介入术中均未发生并发症.结论 在我国没有专门逆向PCI工具的情况下,如果室间隔支不适合作为逆向通道,心外膜下侧支循环在符合一定条件时也可作为逆向通道,进行CTO病变的逆向PCI.     

Anomalous right coronary artery angioplasty complicated by intramural hematoma in the ascending aorta

An iatrogenic intramural hematoma (IMH) localized in the ascending aorta is a rare and potentially life-threatening complication following percutaneous coronary intervention (PCI). We describe the case of an ascending aortic IMH after the PCI of an anomalous right coronary artery. Early extension of the hematoma was observed during transesophageal echocardiography; the patient underwent successful surgical repair.     

A Detailed Analysis of Perforations During Chronic Total Occlusion Angioplasty

ObjectivesThis study sought to describe the angiographic characteristics, strategy associated with perforation, and the management of perforation during chronic total occlusion percutaneous coronary intervention (CTO PCI).BackgroundThe incidence of perforation is higher during CTO PCI compared with non-CTO PCI and is reportedly highest among retrograde procedures.MethodsAmong 1,000 consecutive patients who underwent CTO PCI in a 12-center registry, 89 (8.9%) had core lab–adjudicated angiographic perforations. Clinical perforation was defined as any perforation requiring treatment. Major adverse cardiac events (MAEs) were defined as in-hospital death, cardiac tamponade, and pericardial effusion.ResultsAmong the 89 perforations, 43 (48.3%) were clinically significant, and 46 (51.7%) were simply observed. MAE occurred in 25 (28.0%), and in-hospital death occurred in 9 (10.1%). Compared with nonclinical perforations, clinical perforations were larger in size, more often at a collateral location, had a high-risk shape, and less likely to cause staining or fast filling. Compared with perforations not associated with MAE, perforations associated with MAE were larger in size, more proximal or at collateral location, and had a high-risk shape. When the core lab attributed the perforation to the approach used when the perforation occurred, 61% of retrograde perforations by other classifications were actually antegrade.ConclusionsLarger size, proximal or collateral location, and high-risk shapes of a coronary perforation were associated with MAE. Six of 10 perforations occurred with antegrade approaches among patients who had both strategies attempted. These finding will help emerging CTO operators understand high-risk features of the perforation that require treatment and inform future comparisons of retrograde and antegrade complications.     

The safety and feasibility of bilateral radial approach in chronic total occlusion percutaneous coronary intervention

Few studies have reported results for transradial (TR) percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) lesions. The purpose of this study was to evaluate the feasibility and safety of bilateral radial PCI for CTO lesions.Eighty-five consecutive patients with CTO lesions received PCI via a bilateral TR approach. A high radial artery puncture (10-15 cm above styloid process) accommodating a 7 Fr catheter (85 cm long) was used for a retrograde approach, and a 6 Fr catheter was used in the other radial artery for an antegrade approach. Retrograde wiring was conducted primarily or after failure of antegrade wiring. Mean duration of CTO was 42.8 ± 54.9 months. Vessels with occlusions attempted were the left anterior descending artery (40.0%; 34/85), right coronary artery (58.8%; 50/85), and left circumflex artery (1/85). PCI re-attempts were made in 41.2% of the cases. The overall success rate was 87.1%. Retrograde wiring was successful in 61/85 cases (71.8%), via septal collaterals followed by epicardial collaterals and saphenous vein graft. There were no major complications (30 day in-hospital death, Q wave myocardial infarction, or emergency bypass surgery), or serious access site complications.For experienced TR-PCI operators who are already doing complex TR coronary interventions, the bilateral radial approach for CTO lesions appears feasible and safe.     

Different strategies of retrograde approach in coronary angioplasty for chronic total occlusion

Background:

Retrograde approach through the collateral channels has been recently proposed and has the potential to improve the success rate of percutaneous coronary intervention (PCI) in chronic total occlusion (CTO) lesions of the coronary arteries.

Methods:

The author performed retrograde approach for CTO lesions in 45 patients from January 2006 to January 2007 at different medical institutions worldwide. The details of the techniques were examined retrospectively.

Results:

The septal branch route was used in 93% of the cases. The author classified the strategies into six types after the successful crossing of a guidewire into the target artery distal to the CTO lesion through the collateral channels. Among them, “Just landmark,” “Controlled antegrade and retrograde subintimal tracking,” and “Proximal true lumen puncture” strategies were used most frequently (32, 27, and 30%, respectively). The retrograde guidewires could be successfully passed distal to the CTO lesion in 37 patients (82%), among them the final PCI success was achieved in 31 patients, yielding the PCI success by pure retrograde approach of 69%. The final success rate among 45 patients including 42 patients with previous failed attempts was 84% (38 patients). There were no serious complications related to the retrograde approach.

Conclusions:

Retrograde approach with different strategies, mainly through septal arteries, can provide a high success rate with PCI, as shown in 83% of patients with previous failed attempts at traditional PCI for CTO lesions, with there being no serious complications. More experience of this technique and its refinement are required for further improvement of PCI techniques for CTO lesions. © 2008 Wiley‐Liss, Inc.     

Thyrocervical trunk perforation: A rare vascular complication during cardiac intervention through right radial approach: A case report and literature review

Trans radial artery access (TRA) is considered a relatively safe approach for percutaneous coronary intervention (PCI), by virtue of its fewer access related peripheral vascular complications. Central arterial complications are rare. We are presenting a case report wherein thyrocervical trunk (TT), a branch of first part of right subclavian artery (RSA) was perforated during intervention through right radial approach, resulting in deep neck hematoma, compressing the trachea and surrounding structure. To our knowledge, this is the first reported case of TT perforation by a hydrophilic wire during a staged cardiac catheterization after primary PCI through right radial approach. Knowledge of such a rare complication, its early recognition, and endovascular treatment might spare a patient with recent acute coronary syndrome on double antiplatelet medications, from surgical intervention and fatal outcome.     

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 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.     

Angiographic success and procedural complications in patients undergoing retrograde percutaneous coronary chronic total occlusion interventions: A weighted meta-analysis of 3482 patients from 26 studies

Background

The efficacy and safety profile of retrograde chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has received limited study. We sought to perform a weighted meta-analysis of the success and complication rates of retrograde CTO PCI.

Methods

We conducted a meta-analysis of 26 studies published between 2006 and April 2013 reporting in-hospital outcomes of retrograde CTO PCI. Data on procedural success, frequency of death, emergent coronary artery bypass graft surgery (CABG), stroke, myocardial infarction (MI), perforation, tamponade, stent thrombosis, major vascular or bleeding events, contrast nephropathy, and radiation skin injury were collected.

Results

A total of 26 studies with 3482 patients and 3493 target CTO lesions were included. Primary retrograde CTO PCI was attempted in 52.4%. Pooled estimates of outcomes were as follows: procedural success 83.3% [95% confidence interval (CI): 79.0% to 87.7%]; death 0.7% (95% CI: 0.5% to 1.2%); urgent CABG 0.7% (95% CI: 0.4% to 1.2%); tamponade 1.4% (95% CI: 1.0% to 2.2%); collateral perforation 6.9% (95% CI: 4.6% to 10.4%); coronary perforation 4.3% (95% CI: 1.2% to 15.4%); donor vessel dissection 2% (95% CI: 0.9% to 4.5%); stroke 0.5% (95% CI: 0.2% to 1.0%); MI 3.1% (95% CI: 0.2% to 5.0%); Q wave MI 0.6% (95% CI: 0.4% to 1.1%); vascular access complications 2% (95% CI: 0.9% to 4.5%); contrast nephropathy 1.8% (95% CI: 0.8% to 3.7%); and wire fracture and equipment entrapment 1.2% (95% CI: 0.6% to 2.5%).

Conclusions

Retrograde CTO PCI is associated with high procedural success rate and acceptable risk for procedural complications.     

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.