Coil embolization of perforation after transradial … Kamishima.pdfIntroduction •Use of the trans...

Coil embolization of perforation after transradial coronary intervention

Tokyo Women’s Medical UniversityDepartment of Cardiology

Kazuho Kamishima, Atsushi Takagi,Dai Okayama, Suguru Nakao, Hiroyuki Arashi, Norihiro Yamada,

Junichi Yamaguchi, Nobuhisa Hagiwara

TCTAP2013

Introduction

• Use of the trans radial approach for PCI has increased in coronary angiography and intervention cases.

• Arterial perforation is a rare complication during the trans radial approach, occurring less in less than 1% of cases.

TCTAP2013

Case72 y/o MaleDiagnosis) effort APClinical History)

1984 CABG(SVG-OM, LITA-LAD) in 1984,1991 re-CABG(GEA-LAD, SVG-#4AV) 2000 PCI to SVG-OM and distal RCA(#3) with BMS 2011 PCI to SVG-OM body with BMS(Integrity) 2012 ICD implantation2012 CRT-D up grade

TCTAP2013

CAG(native coronary)

TCTAP2013

LCA RCA

CAG(graft)

GEA-LAD SVG-OM

TCTAP2013

PCI procedure

• CAG revealed restenosis of BMS in SVG.

• PCI was performed by transradial approach.

• We exchanged the 5Fr radial sheath for 6Fr.

• It was difficult to engage guide catheter to SVG. Thus we changed guide catheter 3 times. Finally, AL-2.0 was suitable. However, back up force of guide catheter was insufficient.

TCTAP2013

PCI to SVG body

TCTAP2013

Promus Element 3.5*12

TCTAP2013

30min after PCI, patient complained pain

and…

Subclavian artery angiography

TCTAP2013

Perforation

ITA

Subclavian A

Lateral

thoratic A

Selective injection pectral artery

TCTAP2013

Procedure for artery embolization

• Despite compression of chest centered on bleeding site under fluoroscopic guidance, bleeding continued.

• Negative pressure with micro catheter was not effective, either.

• The decision was made to perform coil embolization.

TCTAP2013

Coil embolization

TCTAP2013

Figure 2.0/5 (Boston Scientific)× 3 Bleeding continued!

Fat emblization

TCTAP2013

Take home message

• It is necessary to identify the tip of the guide wire during catheter exchange to avoid guide wire perforation of the side branch.

• Addition of fat embolization was effective when coil embolization was inadequate.

TCTAP2013