A brief review of complications and tips and tricks Emmanouil Brilakis, Minneapolis, USA 10th Experts „Live“ CTO Workshop - Day2

1. EURO CTO CLUB
Toulouse 2018
A brief review of complications and
tips and tricks
Emmanouil S. Brilakis, MD, PhD
Minneapolis Heart Institute
14.50 – 15.05
Saturday, September 15, 2018

2. EURO CTO CLUB
Toulouse 2018
Disclosure Statement of Financial Interest
• Consulting/speaker honoraria: Abbott Vascular, American
Heart Association (associate editor Circulation), Amgen,
Boston Scientific, CSI, Elsevier, GE Healthcare, Medtronic.
• Research support: Osprey, Regeneron, Siemens.
• Shareholder: MHI Ventures.
• Board of Directors: Cardiovascular Innovations Foundation
• Board of Trustees: Society of Cardiovascular Angiography
and Interventions

3. Disclosures
Consulting/speaker honoraria: Abbott
Vascular, Amgen, Asahi, CSI, Elsevier,
GE Healthcare, Medicure
Employment (spouse): Medtronic
Grants: Boston Scientific, Osprey
VA CSP#571 – DIVA

4. 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

5. 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

6. Dual
injection

7. True to true
crossing
into aorta

8. Chest pain
and
hypotension

9. LAD wiring
and balloon
TIP 1
Insert “safety wire” into
donor vessel during CTO PCI

10. Stent placed in
LAD over
retrograde
guidewire
(microcatheter
removed)

11. Final LAD

12. 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

13. Survey of 1,149 cardiologists on CTO PCI
Patel S, Menon RV, Burke MN, Jaffer FA, Yeh RW, Vo M, Karmpaliotis D, Azzalini L, Carlino M, Mashayekhi K, Galassi A, Rinfret S, Ellis S, Patel M,
Rangan BV, Karatasakis A, Danek BA, Karacsonyi J, Resendes E, Banerjee S, Brilakis ES. J Invasive Cardiol. 2017; in press

14. Brilakis ES. Manual of coronary CTO interventions 2nd edition. Elsevier 2017

15. Types of coronary perforation
Main Vessel
perforation
Distal Wire
perforation
Collateral
perforation

16. Brilakis ES. Manual of coronary CTO interventions 2nd edition. Elsevier 2017
Sealing a large vessel perforation

17. Baseline Angiography
RCA CTO

18. Retrograde

19. Wire externalization
Retrograde Corsair

20. After stenting

21. Balloon rupture during
postdilation
TIP
Balloon rupture can
cause perforation
TIP 4
When a balloon ruptures do
an angiogram immediately!

22. Brilakis ES. Manual of coronary CTO interventions 2nd edition. Elsevier 2017
Could NOT deliver
Graftmaster covered stent
due to severe calcification
(despite externalized
guidewire)

23. After hours of
ballooning

24. Leak continues…

25. More balloon inflations

26. 3 hours later: wire
removed then
protamine given
•Balloon rupture can lead
to perforation
•If unable to deliver
covered stent, prolonged
balloon inflation can
achieve hemostasis
•Heparin reversal delayed
until after equipment
removal from coronary
arteries
Conclusions

28. LAD CTO

29. Predilation
– balloon
rupture
next step?
TIP
Severe
calcification
increases risk for
perforation

30. Stop
bleeding
TIP
The first step in any
perforation is to inflate a
balloon proximally to stop
pericardial bleeding

31. Ping-pong

32. Unable to
deliver
2.80x19 mm
Graftmaster
TIP
Delivery of covered stents
can be very challenging

33. Covered
stent
through
Guideliner
TIP
Graftmaster stents can fit
within an 8 Fr guide
catheter extension

34. Perforation
sealed

35. ACT=227
TIP
Perforation can be further
complicated by thrombosis
DON’T REVERSE HEPARIN UNTIL
AFTER EQUIPMENT REMOVED
FROM CORONARY ARTERY

36. Final result

37. TTE at the end
TIP
Early balloon inflation can
prevent tamponade

38. Proximal cap: Blunt stump
Length: ~50 mm
Distal vessel: Good quality
Collaterals: Epicardial
RCA CTO
PLAN
1. AWE
2. Retrograde via epicardial collateral
3. ADR
Alternative perforation treatment

39. Confiaza Pro 12

40. TurnPike LP
Fielder XT

41. Why
orthogonal
projections are
important!
Next step?

42. What not to
do!
Next step?
TIP
Extraluminal
microcatheter: do
NOT remove until
Rx plan is in
place

43. 2.5 mm
balloon
Sion
TurnPike LP

44. Postdilation with 3.0 mm NC balloon

45. Final result
Procedural time: 259 min
AK Radiation: 1.378 Gray
DAP: 12,187 mcGray
Conclusions
• Confirm wire location before
advancing microcatheter!
• Do not remove extraluminal
microcatheter before you have
a plan
• Subintimal CTO recanalization
can seal a perforation
• Aortocoronary dissection:
stent the ostium + stop
injecting!

46. Types of coronary perforation
Main Vessel
perforation
Distal Wire
perforation
Collateral
perforation

47. Brilakis ES. Manual of coronary CTO interventions 2nd edition. Elsevier 2017
Distal vessel perforation

48. Brilakis ES. Manual of coronary CTO interventions 2nd edition. Elsevier 2017
Distal vessel embolization
Block and deliver

49. Coil vs. fat embolization
Fat Coil
Visibility 0 +
Controlled
delivery
0 +
Catheter needed
for delivery
Any microcatheter Larger microcatheter*
Availability Universal Often limited
Cost 0 High

51. A C
B D
TIP
Fat floats!

52. RCA CTO

53. Distal vessel
perforation

54. “Universal” Algorithm for
Coronary Perforations
Type-specific
Treatment
}
}

55. Currently used coils in our lab
Axium – ev3 Azur – Terumo
Finecross 1.8 Fr Progreat 2.8 Fr
TIP
Learn your coils

56. Block +
Deliver

57. Coil 3

58. Bleeding
continues
Tip
Bleeding may not
stop immediately
after coiling

59. Bleeding
stopped
(finally…)

61. TIP
Contrast echo to
ensure pericardial
bleeding has stopped

62. Brilakis ES. Manual of coronary CTO interventions 2nd edition. Elsevier 2017
Covered stent for distal perforation
1

63. Brilakis ES. Manual of coronary CTO interventions 2nd edition. Elsevier 2017
Covered stent for distal perforation
2

64. Types of coronary perforation
Main Vessel
perforation
Distal Wire
perforation
Collateral
perforation

65. TIP
Epicardial collateral
perforation requires sealing
from both sides

66. Brilakis ES. Manual of coronary CTO interventions 2nd edition. Elsevier 2017
Sealing an epicardial collateral perforation

67. ASSESSMENT
Target vessel:
mid circumflex
Proximal cap: No stump
Length: 50 mm
Distal cap:
Diseased distal
vessel
Collaterals:
Septal and
epicardial
PLAN
1. Retrograde (via septal)
2. AWE
3. Retrograde (via epicardial)

68. Septal crossing failed

69. Caravel + Suoh 03

70. Caravel
Fielder XTR

71. Epicardial collateral perforation

72. Minimal effusion

73. sleeping

74. Woke up
TIP
Pulsus paradoxus not
always due to tamponade

75. Contrast
echocardiography to
rule out continuous
extravasation
Pulsus paradoxus

76. After protamine – perforation sealed - pleuritic chest pain - recovery
TIP
Protamine may seal
perforation

77. Wilson et al. CCI 2015;86:407–41
TIP
Perforation in the post
CABG patient can be a
lethal complication –
TREAT IT IMMEDIATELY!

78. 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

80. PROspective Global REgiStry for the Study of CTO
interventions
www.progresscto.org
Radiation exposure
2012-2015
9 centers, 748 lesions
Procedural success: 90%
Median AK dose: 3.4 (2.0, 5.4) Gray
Christakopoulos G, Christopoulos G, Karmpaliotis DK, Alaswad K, Yeh RW, Jaffer FA, Wyman MR, Lombardi WL, Tarar MNJ, Grantham JA,
Kandzari DE, Lembo N, Moses JW, Kirtane AJ, Parikh M, Green P, Finn M, Garcia S, Doing AH, Hatem R, Thompson CA, Banerjee S, Brilakis ES.
Can J Cardiol 2017 Apr;33(4):478-484.

81. How can you reduce radiation dose?
INTENSITY TIME DISTANCE SHIELDING
1 2 3 4

82. How can you reduce radiation dose?
INTENSITY
1

83. Brilakis ES. Manual of coronary CTO interventions. Elsevier 2017
1. Image receptor
“touching” patient
2. Table position not
too low
3. Avoid steep
angulations
4. No body parts in
field of view
5. Move as far away as
possible

84. Avoid extreme angulations
Agarwal S wt al. Circ Interv 2014;7-447-455

86. 1.3 Collimation

87. 1.4 Low
magnification

88. Martinez-Parachini R et al. ACC 2017

90. Deliver optimal
image quality in
clinically-relevant
region
While
maintaining
appropriate
resolution in
periphery
Resulting in
75%+ radiation
dose reduction
to patient and
physician
No clinical value to radiate entire field-of-view at same levels

91. How can you reduce radiation dose?
TIME
2
INTENSITY
1

95. Abdelaal E. JACC Interv 2014;7:567-574
30%↓
19%↓

96. How can you reduce radiation dose?
INTENSITY TIME DISTANCE
1 2 3

98. Tube extension
Christopoulos G. et al. Catheter Cardiovasc Interv 2016;87:291-301

99. Don’t X-ray your hands!!!
Quick access needle holder

100. How can you reduce operator radiation dose?
INTENSITY TIME DISTANCE SHIELDING
1 2 3 4

102. Fixed shields
Brilakis ES. Manual of coronary CTO interventions. Elsevier 2013

105. RadPad and operator dose
Shorrock et al. J Invasive Cardiol 2015;27:313-316
69 CTO PCIs with
RadPad compared
with 55 non-CTO
PCIs without
RadPad
Operator
exposures were
similar, despite 2-
3X greater patient
exposure

106. Better
protection
Radiation helmet
“Shin guards”

107. El-Sayed T et al. Radiation Induced DNA Damage in Operators Performing Endovascular Aortic Repair. Circulation 2017

108. Ceiling-suspended shield

110. How can you reduce radiation dose?
INTENSITY TIME DISTANCE SHIELDING
1 2 3 4

111. vs.

112. 0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
mrem
Control
1.
1
1.
4
0.
7
p<0.001 p<0.001p=0.323
36% relative
reduction in
overall
radiation!
1.
0
1.4
0.9
Christopoulos G. Circ Cardiovasc Interv 2014;7:744-750

113. Radiation is bad:
•Skin injury
•Cancer
•Deterministic
•Stochastic
BUT
There are MANY actions and
technologies that can help
minimize those hazards
DO SOMETHING
ABOUT IT

114. Conclusions
1. Know what can go wrong and what you
can do about it
2. Closure: Safety wire in donor vessel
3. Perforation “Universal Algorithm” +
covered stents + fat + coils
3. Radiation: intensity-time-distance-
shielding
4. Remain calm – communicate with team www.progresscto.org
www.ctomanual.org