Coronary perforation, complication during PTCA

1. CORONARY PERFORATION
 Definition- Evidence of extravasation of contrastmedium or blood from
the coronary artery during or following percutaneous intervention.
 Anatomically classifiedas:-
1) Proximal/ mid vessel
- Usually more profound with greater likelihood of significant
sequelae.
-
2) Distal vessel
- Etiology is often guide wire (WIRE EXIT).
- Clinical courseis frequently benign
Other classification
Fukutomi
Type 1- Epicardial staining without a contrast extravasation.
Type 2- Epicardial staining with a visible jet of contrast extravasation.
Kini
Type 1 – Myocardial staining without contrast extravasation

2. Type 2- Contrast extravasation into pericardium, coronary sinus or cardiac
chambers.
Incidence
 0.5%
 Complication rate:-
◦ POBA -0.1%
◦ Excimer laser -1.9%
◦ Rotational atherectomy – 1.3%
Lesion prone for perforation
 CTO (27%)
 Calcification
 Tortuosity
 Eccentric plaque
 Bifurcation lesion
 AHA/ACC class B/C lesion
 Small calibre vessel (<2.5mm)
Patient relatedrisk factors
 Older age
 Previous CABG
 Lower creatinine clearance
Other risk factors
 Device-lumen mismatch
 Oversized compliant balloons (Balloon to artery ratio>1.2).
 High inflation pressure
 In case of perforation, GP 11b-111a inhibitors, is a/w
- Higher incidence of tamponade
- Greater requirement of emergency surgery.

3. - Guidewires
 Hydrophilic wire more prone for CAP
 More likely to cause distally, in the terminal sub-branches
 Less likely to cause frank rupture than a high pressure balloon
barotrauma
 most of the guide wire mediated rupture is Ellis type1 or type 2
 Prevention- create loop at the end of the wire.
Prevention
 Keep ACT optimum
 IIIa-IIb use when indication is must
 UFH is preferable to Bivaluridin in complicated cases becauseeasy
reversal with protamine
 Multiple views
 Dual injections
 Delayed watch

4.  Start with workhorse wire or hydrophilic tipped/ stiff wires that are used
to get through difficult lesions should be exchanged for workhorse wires
with softer hydrophobic tips
 IVUS
 Confine wire to true lumen
 Do not dilate in side branch or collaterals
Supportive measures:-
 I/V fluids
 Oxygen
 Analgesia
 Ionotropic support
 Atropine
 IABP
Type 1 perforation treatment
 Usually respond to conservative measures.
 Close monitoring
 Serial echocardiography

5.  Repeated injections of contrastmedia every 15-30 minutes
 No further action is required if degree of extravasation does not increase
or diminishes.
 Increased extravasation is treated with reversal of anticoagulation and/or
prolonged balloon inflation at or proximal to the perforated segment.
Type 2/3 perforation
 Proximal/ mid vessel- Inflate balloon at the site of bleeding.
 Balloon inflation for upto 30 minutes usually at 2 atm
 If patient cannot tolerate ischemia (uncommon in CTO–PCIdue to
presence of collaterals), then perfusion balloon can be used.
 Microcatheter over another guide wire is positioned distal to site of
perforation and the patient's own arterial blood via microcatheter is
injected (microcatheter distal perfusion technique).
 Anticoagulation- If the procedureis to be discontinued, reversalof
heparin with protamine has shown to be effective. (But this should be
deferred till balloons & wires are still in the artery.
Antiplatelet
 GPI should be discontinued bcoz even trivial blush of extravasation may
progress to severeproblem with this use.
 Abciximab bind irreversibly to platelet receptors, leading to platelet
activity almost negligible for 24-36 hrs.
 Platelet transfusion may be required.
 However, in caseof tirofiban & eptifibatide, simply discontinuing the
infusion is sufficient .
Cardiac tamponade
 Urgent echo & pericardiocentesis.
 If there is no resolution of bleeding at 30 minutes, further action is
required including surgery.

6.  If the bleeding frompericardial tube is persistat a rate of 10mlper
minute, despite mechanical & pharmacologicalaction, surgery is
indicated.
 Measurein deploying covered stent- Deployed at high pressure(14-16
atm) with prolonged balloon inflation to allow optimal stent expansion –
to ensure sealing of perforation & to reducethe risk of stent thrombosis
1) JOSTENTGraftMaster
 Stainless steel stent covered with polytetrafluoroethylene (PTFE)
 Wall thickness - 0.3mm
 Size - 3.0 to 5.0.
 Minimum Guiding catheter 6 to 7 F
 Bulkier than other covered stents
2) In situDirect stentstent-graft
 Stainless steel PTFE covered stent.
 Wall thickness 0.15mm
 Thinnest covered stent available (starting at 1.2mm.

7.  Size – 2.5mmto 6.0mm
 Minimum Guiding catheter 6 to 7 F
3) Over & Under pericardiumcoveredstent
 Stainless steel stent covered with equine pericardium (105 um
thickness).
 Highly flexible
 Size- 2.5 to 4.0mm
 More biocompatible, less risk of stent thrombosis.
4) PK Papyrus coveredcoronary stent
 Cobalt chromium stent covered with polyurethane(90um thickness)
 Highly flexible with low crossing profile.
 Size- 2.5 to 5.0mm
 Guiding catheter- 5 to 6Fr
 Low crossing profilereduces the stiffness of crimped stent graftby upto
58%
Limitation of covered stents
 Bulkier than normal stents
 Reduced flexibility & trackability.
 Increserisk of stent thrombosis (5.7%)& restenosis (29%)
Dual guiding catheter technique
Aim– to reduce the time between deflation of sealing balloon & final delivery
of the covered stent at the perforation site
Steps-
 Sealing ballon is infalted
 Guide catheter is withdrawn slightly from coronary ostia
 Another guiding catheter (7Fr/8Fr) inserted from C/L femoral artery &
engage the samecoronary ostia.

8.  Covered stent graft(or coil in case of smaller & distal vessel) is
advanced on a new wire via second guide catheter & placed just
proximal to the sealing balloon.
 Sealing balloon is deflated & withdrawn proximally to allow passageof
wire & covered stent which is to be deployed
 Sealing balloon, wire & guide catheter is removed only after gaining
adequate seal of the lesion with covered stent