Complications of Pc i

7/28/2019 Complications of Pc i

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Complications ofPercutaneous Coronary

Intervention

John S. Douglas Jr. MDJohn S. Douglas Jr. MD

Professor of MedicineProfessor of Medicine

Emory University School of MedicineEmory University School of Medicine


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Complications of PCI

RecognitionPrevention Management

The Basics


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Complications of Percutaneous

Coronary Intervention

Ischemic Events

Stent Misadventures

Aortic Injury

Coronary Perforation


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Basis of Major Ischemic

Complications

Vessel Closure

Distal Embolization

Myocardial Infarction

Ischemic LV Dysfunction

Emergency CABG

Death


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Emergent CABG in 41 Patients

During 5875 PCI (0.7%) 1995-2000

Dissection

Maldeployed Stent

Perforation

Wire Failure

Clot Etc

Reasons For CABG

Hopkins et al CCI 2001;53:99


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Emergency Bypass Surgery

1979-2003

N= 23,087

Yang et al J Am Coll Cardiol 2005; 46: 2004


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Coronary Dissection Remains a

Significant Problem in the Stent Era

! Plaque fracture (due to

balloon inflation or stent)

! Guide catheter or wire trauma

! Balloon rupture


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Predictors of Stent Thrombosis

Dissection Odds Ratio 3.8

Stent Length Odds Ratio 1.3

MLD Odds Ratio 0.4

20% Mortality Occurred

Cutlip et al Circulation 2001;103:1967

6186 patients dual antiplatelet therapy

Stent Thrombosis 0.9%


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Balloon Induced Dissection Treated

Successfully with Stenting


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Left Main Dissection

Safian et al

Treatment: CABG, emergency stent if unstable


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Common Mechanism of Left Main

Injury from Left Amplatz Guide


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Left Main Injury Following LAD Stent


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Left Main Injury Treated with Stent Implantation


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Iatrogenic Aortic Dissection

Rare Complication

Secondary to guide catheter trauma, injection of

wedged catheter or balloon rupture

Class 1: Limited to coronary cusp

Class 2: Limited to cusp and proximal ascending

aortaClass 3: Extending to Aortic Arch


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Class 1 Dissection Into the Right

Coronary Cusp Successfully Treated

with Stent Implantation

Dunning et al Cathet. Cardiovasc. Intervent. 51:387, 2000.


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Class 2 Dissection Extending Into

the Aorta with RCA OcclusionRequiring CABG



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Class 2 Dissection Above the RCA Treated

Successfully with RCA Stent


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Class 3 Dissection Extending Into the

Aortic Arch with Fatal Outcome



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Embolic Consequences of PCI

No Reflow

Myocardial Necrosis


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Distal Embolism During Native (130) and SVG

(64) PCI Use of Filters

194 consecutive filter patients

STEMI 38%, NSTEMI 32%, Angina 29%

Major debris (particles >1mm dia.) was retrieved in 55%

The only predictor of major debris was longer stent length(P


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Pre and Post PCI MRI and Troponin

Demonstrate Myonecrosis Mostly Due To

Distal Embolization50 consecutive patients all on Plavix + Reopro

New Hyperenhancement 28% (all had!Troponin)

Stent length correlated with injury (P=0.04)

Selvanayagam et al Circulation 2005;111:1027-1032

Correlation between troponin I and mass of

hyperenhancement (amount of irreversible injury)


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Patterns of Post-PCI Hyperenhancement

Representing Focal Myo-necrosisRarely Observed Adjacent To Stent



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Patterns of Post-PCI Hyperenhancement

Representing Focal Myo-necrosis

Commonly Observed New Apical Defect DueTo Embolization



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SAFER Trial Comparison of PercuSurge

to Routine Stenting in SVGs

801 Patients Randomized

30 Day MACE

Reduced 42%

P


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Management of No Reflow

Avoid by using embolic protection and IIb / IIIa

inhibitors when appropriate

Support the patient (IABP if needed)

Aspirate stagnant dye column

Deliver microvascular dilators distally Nipride or Calcium blocker 50 to 100 mcg bolus

Adenosine 10 to 30 mcg doses (t! < 20sec)


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Stent Maldeployment

Imprecise placement

Stent entrapment in uncrossable lesion Unexpandable lesion

Sheared off by guide catheter

Lost!


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Stent Embolization

Systemically generally safe

Intracoronary

Deploy (if on wire)

Crush (if off wire)

Retrieve with snare or wrapped in parallelguide wires


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To Avoid Stent Misadventures

Predilate difficult lesions (rigid ortortuous)

Cutting balloon or rotablation forundilatable or calcified lesions

>20 atm achievable if needed(Quantum Maverick or Power Sail)


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Coronary perforation during

PCI in the IIb/IIIa Era

J Am Coll Cardiol 1999; 33, 72A

Cleveland Clinic5,500 Patients; 31% Abciximab; 9 Deaths

Perforation Death

0

30

%

1.3 1.56%

24%

No Abciximab

Abciximab

P=0.02


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Coronary Perforation Classification

Contrast jet through > 1mm exit holeType 3

Pericardial or myocardial blush without

> 1mm exit hole

Type 2

Crater extending outside lumen onlyType 1

Ellis et al. Circulation 1992; 88: I-787


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Causes of Coronary Perforation During PCI

1995-1999 at Christ Hospital

36 Perforations

Guide

WireBalloon Stent Rotablater DCA Laser/TEC

Dippel et al. Cathet Cardiovasc Intervent 2001; 52:279-286

NumberofPatients

0

15

5

10

Odds Ratio

Perf. 16

Type 3 Perf. 29


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Risk associated with

Type 3 Perforation

43%63%Tamponade

50%75%Surgery

29%QMI

21%14%Death

Dippel et al. 2001Ellis et al. 1992


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Cardiac Tamponade Complicating PCI

An 8 year experience at

William Beaumont Hospital

Fejka et al. Circulation 2001; 104: II-417

%

36 Patients

In-Lab

56

Out-of-Lab

(mean 5 hours)

Surgery MI Death

4439

29

42

60

0


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JoMed PTFE Covered Stent for

PCI Perforations

Lansky et al. JACC 2000; 35: 26A

Multicenter Study of 35 Patients

0Death

0Emergency Surgery

0Q Wave MI

100%Complete Sealing

14%Tamponade22%Pericardial effusions


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Type 2 Perforation Following Stent

Implantation


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Type 2 Perforation Following

Stent Implantation

Perfusion Balloon


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Prolonged Balloon Inflation


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Small Stain Noted on the Inferior

Wall During RCA Stent Procedure

Reopro Discontinued


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Tamponade 3 hrs later: Balloon Occlusion

Sealed Perforation Only After Distal Platelet

Injection


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PCI of Chronic Total OcclusionDifficult Wire Passage


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Inflation of 1.5mm Balloon


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Inflation of 1.5mm Balloon


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Type 3 Perforation Treated with

Coil Embolization


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Type 3 Perforation of LIMA to LAD


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Complete sealing of perforation with covered stent


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Coronary Perforation

- Diagnosis -

! Angiographic (blush, jet, coronary sinus

compression, contrast in pericardium)

! No angiographic evidence in 10-20%

! ECHO (Not needed in 50% at Beaumont)

! Delayed tamponade common (wire induced &

IIbIIIa)


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Management of Coronary Perforation

Hemodynamic Support! Volume and inotropes

! Pericardiocentesis (pigtail)

! IABP (to resussitate)

Seal Perforation! Reverse heparin

! Balloon occlusion (perfusion balloon)

! Platelets (abciximab)

! Embolization (coil, gel foam, thrombus)! Covered stent (Jomed available)

! Surgery


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Conclusion

! Complications of PCI have decreased with

routine use of intracoronary stents

! However, abrupt closure, perforation and

atherothromboembolization continue to challenge

the interventionalist.

! Attention to prevention, recognition andtreatment of these complications is essential to

performance of safe PCI

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Complications of Pc i