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Perforation Management
of the CTO Vessel
Achim Büttner
EuroCTOClub Berlin 2019
Germany
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I do not have any potential conflict of interest to report
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PROGRESS CTO Registry: Procedural Complications
Presentation Tajti P, SCAI 2018
AWE = Antegrade Wire Escalation
ADR = Antegrade Dissection Reentry
Retrograde
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Perforation - Classification
Risk of
tamponade
8%
13%
63%
Ellis et al, Circulation 1994;90:2725-30
Harries et al, Eurointervention 2014; 10:646-7
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27
21
50
0
7
43
0
2118
0 0
7
0 0
18
0
10
20
30
40
50
60
Ellis I (21%) Ellis II (26%) Ellis III (53%)
Prolonged balloon inflation Covered stent
Pericardiocentesis Emergency surgery
Death
[%]
Danek et al. Am J Cardiol 2017;120:1285-1292
PROGRESS CTO: Perforation Type and Treatment
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Main vessel perforation: Mechanisms
• Calcified CTO lesion
• Wrong wire course
• Subintimal technique
• Post CABG
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Calcified LCX CTO post CABG: Rupture after post-dilatation of DES
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After PTFE-covered stent graft (= sandwich after DES)
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After 3 months …
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Main vessel perforation: Mechanisms
• Calcified CTO lesion
• Wrong wire course
• Subintimal technique
• Post CABG
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#212652
CTO of RCA
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#212652
Externalisation and balloon dilatation
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#212652
Main vessel perforation Type III
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#212652
After 1. DES and 2. PTFE covered stent
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Main vessel perforation: Mechanisms
• Calcified CTO lesion
• Wrong wire course
• Subintimal technique
• Post CABG
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CTO of RCA: ADR with Crossboss
Courtesy of K. Mashayekhi
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Perforation with CrossBoss
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Retrograde Rescue - CTO
Balloon blockade
from antegrade
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Guideliner assisted Reverse-CART Final result
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Main vessel perforation: Mechanisms
• Calcified CTO lesion
• Wrong wire course
• Subintimal technique
• Post CABG
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CTO of RCA 12 yrs. post (2x) CABG, LVEF 20%
Collateral from LCX to RCA-PLA
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Antegrade wire in distal true lumenUnclear position of both wires
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After 2.0mm balloon: extravasation After DES
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5 x Everolimus stents (190mm)
5 x Graftmaster covered stents
After 4 covered stents
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Cardiac CT (Day 1)
Hematoma (H) with compression of left atrium
→ Hemodynamics: PA syst 40 mmHg; CI 2.0 l/min/m²
H
H
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Echocardiography (TTE)
Day 6 Day 14
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Main vessel perforation: How to treat
• Proximal balloon inflation to occlude vessel
• Stabilisation of hemodynamics (i.v. fluids / pressors)
• Angio and echo for localisation and risk estimation
• Pericardiocentesis if hypotension (with fluoroscopic control)
• Reversal of heparin if bleeding persists (remove intracoronary
devices, flush guide)
• Prolonged balloon inflation
• Covered stentgrafts
• Retrograde rescue-PCI
• Emergency operation
General
More specific
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Covered stent grafts
Papyrus (Biotronik) Be-Graft (Bentley Medical)
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GuideBalloon inflated in proximal
vessel stops bleeding
Microcatheter underneath balloon:
- tip injection
- wire manipulation
- application of coils, thrombin etc.
(Graph modified from Gasparini GL, Catheter Cardiovasc Interv.2018)
Garbo R et al. Catheter Cardiovasc Interv. 2017;89:E75-E83
Coronary perforation: Balloon-Microcatheter Technique
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Ping-pong Technique: Two 6F guiding catheters
Microcatheter underneath balloon for wire manipulation
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Perforation of distal branch: Mechanisms
• Perforation with hard CTO wire
• Wire perforation in post CABG patient
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#168536
CTO of distal RCA (2nd attempt)
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ConfianzaPro12 passes into true distal lumen (PLA)
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Contrast injection after 2nd DES (no collimation):
Wire perforation distal PL-branch
Now floppy
wire in PLA
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After DES implantation over side branch
and blockade with 1.25mm balloon for 15 min …
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Successful occlusion
Injection of microspheres via microcatheter
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Pericardial effusion: Pericardiocentesis 150 ml
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Perforation of distal branch: Mechanisms
• Perforation with hard CTO wire
• Wire perforation in post CABG patient
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Distal branch perforation in a post CABG patient
PCI of RCA CTO 3 months ago Readmission for LCX PCI
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After LCX stenting and kissing balloon with OM2: myocardial stainig
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Some hours later cardiogenic shock
Huge myocardial hematoma compressing LCX branches
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Distal vessel perforation: How to treat
• Staining, no / minimal pericardial effusion:
- Finish PCI, then reverse heparin
- Echo in cath lab and post intervention
• Persistant bleeding, pericardial effusion / tamponade:
- Embolisation via microcatheter
with thrombin / microspheres / fat / coils …
- Covered stent over origin of branch
• Always treat distal branch perforation in post CABG patients
• General recommendations see above
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Microspheres: Polyvinyl alcohol embolisation particles
Application with microcatheter or OTW-balloon (prevent back-flow)
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Finecross 1.8 Fr, Caravel, Corsair Progreat 2.4 Fr
Coils and Microcatheters
Axium – ev3
Codman Helical Xtrasoft
Azur-Terumo,
Boston Figure 8-18
VortX Diamon - 18
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Some issues …
• Reversal of heparin in specific situations
• Sandwich [DES – Stentgraft] or [Stentgraft – DES]
- anti-restenotic ?
- sealing of stentgraft edges
• Leave it or treat it (perforation Ellis I or II, cavity spilling)
• Post CABG CTOs
- no ventricular but atrial tamponade
- increased risk for intramyocardial hematoma?
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Some issues …
• Reversal of heparin in specific situations
• Sandwich [DES – Stentgraft] or [Stentgraft – DES]
- anti-restenotic ?
- sealing of stentgraft edges
• Leave it or treat it (perforation Ellis I or II, cavity spilling)
• Post CABG CTOs
- no ventricular but atrial tamponade
- increased risk for intramyocardial hematoma?