Emory University School of Medicine Complications of PCI : Perforation Requiring Pericardiocentesis , Device Embolization and Snares SCAI Fall Fellows Course 2012 John S. Douglas Jr. MD Professor of Medicine Emory University School of Medicine

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Complications of Percutaneous Coronary Intervention Coronary Perforation Stent Misadventures Snares; other retrieval strategies

Coronary perforation during PCI in the IIb/IIIa Era Cleveland Clinic 5,500 Patients; 31% Abciximab; 9 Deaths 24% 30 P=0.02 No Abciximab % Abciximab 6% 1.3 1.5 Perforation Death J Am Coll Cardiol 1999; 33, 72A

Coronary Perforation Classification Type 1 Crater extending outside lumen only Type 2 Pericardial or myocardial blush without > 1mm exit hole Type 3 Contrast jet through > 1mm exit hole Ellis et al. Circulation 1992; 88: I-787

Causes of Coronary Perforation During PCI 1995-1999 at Christ Hospital 36 Perforations 15 Odds Ratio Perf. 16 Type 3 Perf. 29 10 Number of Patients 5 Guide Wire Balloon Stent Rotablater DCA Laser/TEC Dippel et al. Cathet Cardiovasc Intervent 2001; 52:279-286

Risk associated with Type 3 Perforation Ellis et al. 1992 Dippel et al. 2001 Tamponade 63% 43% Surgery 75% 50% QMI 29% Death 14% 21%

Cardiac Tamponade Complicating PCI – An 8 year experience at William Beaumont Hospital 36 Patients 60 56 44 42 39 % 29 In-Lab Out-of-Lab Surgery MI Death (mean 5 hours) Fejka et al. Circulation 2001; 104: II-417

Type III Coronary Perforation : 56 Cases From The Stent Era (1993-2009 ) Incidence : 56 of 24,465 ( 0.23%) Independent predictors were complex lesion , CTO , rotablation , and IVUS guidance Device implicated : balloon 50% , guidewire 18% , atheroablation 7.2% Treatment strategy : balloon 60% , covered stent 46% , coil 1.8% , multiple methods 39% Al-Lamee et al J Am Coll Cardiol Intv 2011;4 :87-95

Outcomes Following Type III Perforation Tamponade & pericardiocentesis in 29% CPR was required in 20% ; IABP in 20% MI ( 3 X CK-MB ) in 43% In – hospital MACE in 55% ; death in 18% Outcomes with GPI were worse (MI 70% , CABG 30% , death 22% and MACE in 90% ) Stent thrombosis in 8.6% of covered stents Al-Lamee et al J Am Coll Cardiol Intv 2011;4 :87-95

Small “Stain” Noted on the Inferior Wall During RCA Stent Procedure Reopro Discontinued

Tamponade 3 hrs later: Balloon Occlusion Sealed Perforation Only After Distal Platelet Injection

PCI of Chronic Total Occlusion Difficult Wire Passage

Type 3 Perforation Following Inflation of 1.5mm Balloon

Type 3 Perforation Treated with Coil Embolization

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)

Management of Coronary Perforation Hemodynamic Support Volume and inotropes Pericardiocentesis (pigtail) IABP (to resussitate) Seal Perforation Reverse heparin Balloon occlusion Platelets (abciximab) Embolization (coil, gel foam, thrombus) Covered stent (Jomed available) Surgery

Stent Misadventures Imprecise placement Stent entrapment in uncrossable lesion Unexpandable lesion Sheared off by guide catheter Lost!

Common Mechanism of Stent Loss Stent Entrapment Brilakis et al CCI 2005;66:33

Mechanism of Stent Loss Stent “Pulled-Off” the Delivery Balloon Brilakis et al CCI 2005;66:33

Attempt to snare the stent or grasp it with forceps Use twisted wires What Are The Options ? Insert a balloon into the undeployed stent , inflate it and withdraw the stent out of the coronary Attempt to snare the stent or grasp it with forceps Use twisted wires High risk features in CARESS-IN-AMI: extensive ST elevation, new onset LBBB, previous MI, Killip class >2, or LVEF <35%

Retrieval of Stent with Loop Snare Brilakis et al CCI 2005;66:33

Twisted Wire Stent Retrieval Brilakis et al CCI 2005;66:33

Small Balloon Stent Retrieval Brilakis et al CCI 2005;66:33

A 1.5X20 Balloon Was Inserted Inflated ,and Withdrawn

A 1.5X20 Balloon Was Inserted Inflated ,and Withdrawn However the stent could not be pulled out

A 1.5X20 Balloon Was Inserted Inflated ,and Withdrawn And , wire position was suddenly lost

What Are The Options Now ? Leave it in place ? Snare it ? Grasp it with forceps ? Use twisted wires ? High risk features in CARESS-IN-AMI: extensive ST elevation, new onset LBBB, previous MI, Killip class >2, or LVEF <35%

Things You May Wish to Consider Which snare is best ? Shape and size of guide catheter ? Femoral sheath size ? Is imaging optimal ? High risk features in CARESS-IN-AMI: extensive ST elevation, new onset LBBB, previous MI, Killip class >2, or LVEF <35%

Retrieval Devices Brilakis et al CCI 2005;66:33

Final RCA Result

Stent Embolization Systemically – generally “safe” Intracoronary Deploy (if on wire) Crush (if off wire) Retrieve with snare or wrapped in parallel guide wires or on small balloon

Mayo Clinic Experience 11,773 PCI’s ● Stent loss in 0.32% ● Successful retrieval 35/38 - balloon expansion and withdrawal 45% - snare 26% - twisted wires 5% - forceps 12% Brilakis et al CCI 2005;66:33

Conclusion Complications of PCI have decreased with routine use of intracoronary stents However, perforation and stent misadventures continue to challenge the interventionalist. Attention to prevention, recognition and treatment of these complications is essential