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  2. 2. Coronary artery perforation is defined as evidence of extravasation of contrast medium or blood from the coronary artery, during or following percutaneous intervention.
  3. 3. Anatomical CATEGORY – Proximal or mid vessel • Usually more profound with greater likelihood of significant sequelae Distal vessel • There the aetiology is often the guide wire (WIRE EXIT) and the clinical course is frequently benign
  4. 4. CLASSIFICATION • Ellis in 1994
  5. 5. OTHER CLASSIFICATIONS- Fukutomi • Type I: Epicardial staining without a contrast extravasation • Type II: Epicardial staining with a visible jet of contrast extravasation Kini • Type I: Myocardial staining without contrast extravasation • Type II: Contrast extravasation into pericardium, coronary sinus, or cardiac chambers
  6. 6. INITIAL DATA • Ellis and colleagues reported first large scale series derived from data obtained from 11 centres, from 1990 and 1991. • Of 12,900 procedures performed, 62 were complicated by coronary perforation (0.5%).
  7. 7. CURRENT DATA • The incidence of Coronary Artery Perforation (CAP) has not changed significantly over two decades. • It is reported between 0.2% and 0.9%.
  8. 8. RISK FACTORS Patient Factors : Females, Elderly, Frail pts. Presentation: ACS/MI, CSA. Lesion Factors: Calcific Lesions, Tortuous lesions, Tapered vessels, Bifurcation lesions, small calibre,
  9. 9. • A study of 38559 patients with 72 perforations reported that > 40% of perforations were seen in vessels < 2.5mm diameter. •Device-lumen mismatch is more important than the vessel reference diameter. • Perforation was more likely where the balloon to artery ratio was 1.3±0.3 compared with a ratio of 1.0±0.3 where no problem ensued. 1.Javaid A, Buch AN, Satler LF, et al. Management and outcomes of coronary artery perforation during percutaneous coronary intervention. Am J Cardiol 2006;98:911-4. 2.Ajluni S, Glazier S, Blankenship L, et al: Perforations after percutaneous coronary interventions: clinical, angiographic, and therapeutic observations. Catheter Cardiovasc Diagn 32:206– 212, 1994.
  10. 10. RISK FACTORS Material-Balloon selection –1:1 High Pressure but not more with high pressure. Cutting/Angiosculpt-more bulky. •Never remove the balloon out totally before you check with a contrast puff. Hydrophilic wires-Stiffer wires/CTO Drugs: GpIIb IIIa inhibitors
  11. 11. In a study* of 16,298 patients with 95 perforations, GPI were used in 33 cases. When these 33 cases were compared with the other 62 cases (where GPI were not used), they found no difference in • Mortality and • Myocardial Infarction GPI use was associated with • Higher incidence of temponade and • Greater requirement of emergency surgery
  12. 12. • Abciximab binds irreversibly to platelet receptors, rendering platelet activity almost negligible for 24 – 36 hours.  In case of perforation with Abciximab, unlike the small molecules Tirofiban and Eptifibatide, simply discontinuing the infusion of Abciximab will not reverse its effect. • Platelet transfusion may be required to restore bleeding time.  REVASCULARIZATION  BLEEDING BALANCE
  13. 13. ATHERECTOMY • Use of either atherectomy or laser ablative technology = More perforation than in convention balloo/stent PCI. • Ellis1 and colleagues reported that incidence of CAP with balloon angioplasty was 14 OF 908 cases (0.1%), whereas that of debulking techniques collectively was 48 OF 3820 cases (1.3%).
  14. 14. GUIDE WIRES • More likely in the terminal sub branches (LESS IN PROX AND MID). • They are also less likely to cause frank rupture of the vessel than a high pressure balloon barotrauma.
  15. 15. GUIDE WIRES • Hence, the appearance more subtle when the wire is the culprit. • Fasseas classified 86% of guide wire mediated ruptures as Ellis type I or II on angiography. • HYDROPHILIC -80%. •CREATE LOOP
  16. 16. CTO • CTO= HIGH RISK (STRONGEST INDEPENDENT PREDICTOR) • If no balloon inflation where the wire is incorrectly positioned, there is minimal extravasation of contrast & blood. • GPI  withheld until the occlusion is safely crossed & distal tip of the wire is seated intraluminally.
  17. 17. SEQUELE OF CAP Caused by CAP- • Blood loss • Distal ischemia • Pericardial Temponade • Cardiogenic shock • Death
  18. 18. SEQUELE OF CAP Caused by MANAGEMENT STRATEGIES- • Myocardial Ischemia • Acute vessel occlusion • Myocardial infarction • Operative morbidity and mortality • Death
  20. 20. DIAGNOSIS • Not all CAPs are immediately visible. • Many develop tamponade > 2 to 6 h later. • The clinical manifestation may be non-specific, and the patient may simply develop progressive hypotension. • A high index of suspicion essential for timely diagnosis.
  21. 21. MANAGEMENT Supportive Measures– • IV FLUIDS • O2 • Analgesia • Inotrops • Atropine • IABP
  22. 22. Inflate balloon at perforation site •Before inflating a balloon, one should consider myocardial ischaemia related to balloon inflation time.
  23. 23. Inflate balloon at perforation site Left main: Direct covered stenting should be considered Balloon inflation is "sometimes" feasible depending on haemodynamic status Consider re-crossing in LCx or LAD after covered stent implantation with wire in LCx and LAD (CTO guidewires) to preserve side branch patency Consider surgery
  24. 24. Inflate balloon at perforation site PROXIMAL MAIN CORONARY ARTERY Inflation time will depend on haemodynamic status / ischaemic condition. DON’T OVERSIZE , 1:1 balloon / artery ratio. If haemodynamics allow: Wait 5 minutes then deflate and inject to check Repeat 4-5 times as required
  25. 25. Inflate balloon at perforation site Balloon inflation for upto 30 min is required. If the patient can not tolerate ischemia, then perfusion balloon, if available. • Fukotomi reported excellent results using perfusion balloon for Ellis type III rupture
  26. 26. IF FAILED-IMPLANT COVERED STENT 6F GUIDING CATHETER If balloon is inflated at perforation site Insert a second guiding catheter (second arterial access, consider femoral ≥ 7Fr) (DOUBLE GUIDE CATHETER TECHNIQUE) Parallel guide wire Deploy covered stent through second guiding catheter
  27. 27. IF FAILED-IMPLANT COBVERED STENT 7F/8F GUIDING CATHETER If balloon is inflated at perforation site Insert a second guide wire in the same guiding catheter Implant covered stent
  28. 28. IF FAILED-IMPLANT COBVERED STENT 7F/8F GUIDING CATHETER If balloon is out of the guiding catheter  Insert a covered stent directly
  30. 30. Management of a Type IV similar to a Type III . Blood leaks into another cardiovascular cavity (often ventricle or coronary vein).  Symptoms are usually that of a new shunt rather than haemodynamic compromise due to a new pericardial effusion. Type IV better tolerated by the patient than Type III
  31. 31. Type V: Distal segment
  32. 32. Type V may be initially missed as the leak into the pericardium is often small and may requiring panning to the distal vessel to be appreciated. Management may require embolisation of the distal vessel with thrombin, coils or fat. Beware of collateral flow to the affected territory which can cause the perforation to persist despite apparently successful embolisation.
  33. 33. Thrombin injection Thrombin: Potent platelet activator Direct and potent promoter of fibrin clot formation
  34. 34. Thrombin injection PREPARATION: Use the wire lumen of a very small diameter over- the-wire balloon catheter. Prepare thrombin, mixed at a concentration of 50– 100 IU per ml in normal saline Slowly inject 100–300 IU of thrombin via the distal lumen of the inflated balloon catheter over a period of 3–5 min Allow balloon to remain inflated for an additional 10– 15 min if possible.
  35. 35. Thrombin injection TRICKS Very small (approx. 0.5ml) bolus of air can be injected through the microcatheter to further diminish retrograde movement of thrombin. Mix of thrombin with a small amount of contrast to allow visualisation.
  36. 36. COIL EMBOLIZATION Needs expertise: Detachable coils, optimal positioning can be confirmed before releasing Pushable coils, smaller but no repositioning  Deliverable through Micro Catheters
  37. 37. Autologous subcutaneous fat embolisation: For distal guidewire perforation Physical barrier to bleeding Coagulation activator Simple, low-cost and universally available treatment Allow for a subsequent PCI attempt
  38. 38. Autologous subcutaneous fat embolisation: Fat from abdominal or femoral (next to the puncture point) SC tissue: Local anaesthesia Fat globules small enough to be delivered throughout a thrombo-aspiration catheter ≤1mm if 6Fr, ≤ 1.2mm if 7Fr, a microcatheter or a OTW balloon: Pushed by a wire Or "emulsion" with saline serum injection
  39. 39. Autologous subcutaneous fat embolisation: Catheter positioned just close to the perforation to avoid: Large peri-procedural infarction by embolisation into branches Systemic or cerebral embolisation
  40. 40. Post-procedural care Once the coronary perforation has been treated there is still a risk of mortality and close surveillance is required during the first 24 hours. 
  41. 41. Post-procedural care
  42. 42. Heparin reversal should be deferred till balloons and wires are still in the artery. ACT---150-200 GPI IMMEDIETLY STOPPED  WORST PROGNOSIS IF SURGERY WARRANTED
  43. 43. THANK YOU