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Coronary artery perforation

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Coronary artery perforation during PCI

Publié dans : Santé & Médecine
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Coronary artery perforation

  2. 2. Coronary Perforation • 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 categories  Anatomically,perforation iscategorizedas–  Proximalor midvessel • Usuallymore profound with greater likelihood of significantsequelae  Distalvessel • Therethe aetiology isoften the guidewire(WIRE EXIT)andthe clinicalcourseis frequentlybenign
  4. 4. Classification  Themost frequently adopted classificationis proposed byEllisin 1994
  5. 5. Other classifications •Fukutomi1  TypeI: Epicardialstaining without acontrast extravasation  TypeII: Epicardialstaining with avisible jet ofcontrast extravasation •Kini2  TypeI: Myocardial staining withoutcontrast extravasation  TypeII: Contrastextravasationintopericardium, coronary sinus, or cardiacchambers 1.Fukutomi T,SuzukiT,PopmaJJ,et al. Early and late clinical outcomes following coronary perforation in patients undergoing percutaneouscoronary intervention. CircJ2002;66:349-56. 2.Kini AS,Rafael OC,SarkarK,et al. Changingoutcomes and treatment strategies for wire inducedcoronary perforations in the era of bivalirudin use.CatheterCardiovascInterv2009;74:700-7.
  6. 6. Incidence and outcomes  Theincidence of CoronaryArtery Perforation(CAP) hasnot changedsignificantly over twodecades.  It isreported between 0.2%and0.9%.
  7. 7. Diagnosis  Not all perforations are immediately visible oncoronary angiography.  Remarkableproportion of patients maydeveloptamponade more than 2 to 6 hours afterprocedure.  Theclinical manifestation maybe non-specific, andthe patient maysimply develop progressivehypotension.  Ahigh index of suspicion should be maintained in orderto securethe correct diagnosis in atimelyfashion.
  8. 8. Outcomes  In various studies, outcomes depend largely uponthe severity of perforation.  Theoutcome isworseif the temponade developsabruptly within the catheter laboratory, rather than in the delayed fashion in the recovery room orICU.  Outcomes alsodepend upon associatedco-morbidities. o Chronicrenaldysfunction o Pre-procedural impairment of LVfunction o Older patient  Cavitaryspilling type IIIperforation
  9. 9. Lesion characteristics  Calcification  Tortuosity  Eccentricplaque  AHA/ACCclassBor Clesions  Smallcalibre vessel  CTOlesions
  10. 10. Treatment
  11. 11.  Most important step isto recognizeandidentify presenceof aperforation. • High indexofsuspicion  Subtlesigns:Unusualmigration of wire tip,dye staining, unexplained hypotension
  12. 12. Strategy  Strategydependsupon –  Site of theperforation  Severityof theinsult  Hemodynamic stability ofpatient  Persistentbleeding
  13. 13.  Supportive measures  Intravenous fluids  Oxygen  Analgesia  Inotropic support  Atropine  Intra aortic ballooncounterpulsation
  14. 14. Type I perforations  Usually respond to conservative measures.  In anycase,indispensable measuresare: o Fastidiouspost-procedural care o Cautiousmonitoring of hemodynamicparameters o At least one, andif required, serialechocardiographic assessment.
  15. 15. Type II or III perforations  Initial managementissimilar.  First objective isto stopbleeding.  Immediatestepisto inflate aballoon at the site of bleeding if it isin the mid or proximal vessel,andmore distally for a remotely situated wire perforation to buy the time for further strategymaking.  Thisprevents the development of temponade,and favourably altersthe outlook of the situation.
  16. 16.  In significant proportion of cases,prolonged balloon dilatation isall that isrequired.  Ballooninflation for upto 30min isrequired.  If the patient cannot tolerate ischemia,then perfusion balloon, if available maybehelpful.  Fukotomi reported excellent results usingperfusionballoon for Ellistype III rupture Fukutomi T,SuzukiT,PopmaJJ,et al. Early and late clinical outcomes following coronary perforation in patients undergoing percutaneous coronary intervention. CircJ2002;66:349–356.
  17. 17. Covered stent Frank rupture of proximal or mid coronary artery often constitute a tear in the vessel, upto 5 mm in length. Deploying a covered stent isolates the point of haemorrhage from the circulation. The most widely used device is PTFE covered stent. Sandwich design Inflexible, difficult to deliver in certain areas
  18. 18. Distal perforation If conventional measures fail, vessel may be occluded by – Platinum microcoils (Trufill – Terumo) Injection of Thrombin Autologous clotted blood Subcutaneous adipose tissue Tris-Acryl gelatin microspheres Polyvinyl alcohol foam
  19. 19. Emergency surgery Cases not responding to conventional measures are sent for emergency surgery  These perforations are frank ruptures, and not modest distal perforations.  Ellis reports 63% of type III perforations had to go for surgery, while very few of type I or type II underwent surgery.
  20. 20. Surgical outcomes The results are disappointing. The mortality of emergency surgery in reports of both Fejka and Witzke was 50%.
  21. 21. Thank you