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Complications of Percutaneous Coronary Intervention John S. Douglas Jr. MD Professor of Medicine Emory University School of Medicine SCAI International Fellows Course 2012 November 20, 2012 1:20PM
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Disclosure Statement of Financial Interest Within the past 12 months, I or my spouse/partner have had a financial interest/arrangement or affiliation with the organization(s) listed below. Within the past 12 months, I or my spouse/partner have had a financial interest/arrangement or affiliation with the organization(s) listed below. Affiliation/Financial RelationshipCompany Grant/Research Support J&J,Medtronic,Boston Sci,Abbott,Medicines Consulting Fees/Honoraria None Major Stock Shareholder/Equity None Royalty Income None Ownership/Founder None Intellectual Property Rights None Other Financial Benefit None
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Complications of PCI RecognitionPreventionManagement 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 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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Balloon Induced Dissection Treated Successfully with Stenting
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Retrograde 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 Becoming a more common 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 aorta Class 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 Occlusion Requiring CABG Dunning et al Cathet. Cardiovasc. Intervent. 51:387, 2000.
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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 Dunning et al Cathet. Cardiovasc. Intervent. 51:387, 2000.
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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<0.001) Conclusion: Filters should be considered in PCI of long lesions – El-Jack et al J Am Coll Cardiol 2006;47(Suppl A):A213A
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Pre and Post PCI MRI and Troponin Demonstrate Myonecrosis Mostly Due To Distal Embolization 50 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-necrosis Rarely Observed Adjacent To Stent Selvanayagam et al Circulation 2005;111:1027-1032
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Patterns of Post-PCI Hyperenhancement Representing Focal Myo-necrosis Commonly Observed New Apical Defect Due To Embolization Selvanayagam et al Circulation 2005;111:1027-1032
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SAFER Trial – Comparison of PercuSurge to Routine Stenting in SVG’s 801 Patients Randomized 30 Day MACE Reduced 42% P<0.001 Baim et al. Circulation 2002; 105: 1285. RoutinePercuSurge % 0 20 16.5% 9.6%
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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 (t½ < 20sec)
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Management of No Reflow 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 (t½ < 20sec)
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Coronary perforation during PCI in the IIb/IIIa Era J Am Coll Cardiol 1999; 33, 72A Cleveland Clinic 5,500 Patients; 31% Abciximab; 9 Deaths PerforationDeath 0 30 % 1.31.5 6% 24% No Abciximab Abciximab P=0.02
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Coronary Perforation Classification Type 1Crater extending outside lumen only Type 2Pericardial or myocardial blush without > 1mm exit hole Type 3Contrast jet through > 1mm exit hole Ellis et al. Circulation 1992; 88: I-787
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Type 2 Perforation Following Stent Implantation
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Type 2 Perforation Following Prolonged Balloon Inflation
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Causes of Coronary Perforation During PCI 1995-1999 at Christ Hospital 36 Perforations Guide Wire BalloonStentRotablaterDCALaser/TEC Dippel et al. Cathet Cardiovasc Intervent 2001; 52:279-286 Number of Patients 0 15 5 10 Odds Ratio Perf. 16 Type 3 Perf. 29
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Risk associated with Type 3 Perforation Ellis et al. 1992Dippel et al. 2001 Tamponade63%43% Surgery75%50% QMI29% Death14%21%
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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) SurgeryMIDeath 44 39 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 Pericardial effusions22% Tamponade14% Complete Sealing100% Q Wave MI0 Emergency Surgery0 Death0
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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 Occlusion Difficult Wire Passage
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Type 3 Perforation Following Inflation of 1.5mm Balloon
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Type 3 Perforation Treated with Coil Embolization
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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 ● Platelets (abciximab) ● Embolization (coil, gel foam, thrombus) ● Covered stent (Jomed available) ● Surgery
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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 parallel guide wires or on small balloon
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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
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Conclusion ● Complications of PCI have decreased with routine use of intracoronary stents ● However, abrupt closure, perforation, atherothromboembolization and stent regret continue to challenge the interventionalist. ● Attention to prevention, recognition and treatment of these complications is essential
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THANK YOU
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