1. Northeast Georgia Heart Center Interventional Complications: State of the Art Review J. Jeffrey Marshall, MD, FSCAI Past President SCAI, 2012-2013 Director Cardiac Cath Lab Northeast GA Heart Center SCAI Fellow’s Course at Qingdao, CHINA August 23, 2014

2. Northeast Georgia Heart Center Disclosures None

3. Complications of PCI RecognitionPreventionManagement The Basics

4. Northeast Georgia Heart Center Emergency Bypass Surgery 1979-2003 N= 23,087 Yang et al J Am Coll Cardiol 2005; 46: 2004

5. Emergent CABG in 41 Patients During 5875 PCI (0.7%) 1995-2000 Reasons For CABG Hopkins et al CCI 2001;53:99

6. Northeast Georgia Heart Center Emergent CABG from NCDR Database N = 1,378,573 NCDR Institutional Outcomes Report. www.ncdr.com. Jan. 26, 2013 Incidence of “salvage” CABG0.3% Cardiac tamponade0.1% Incidence of cardiogenic shock1.1% Coronary perforation0.4% Incidence of death in cath lab (cath + PCI)0.9%

7. Complications of Percutaneous Coronary Intervention Ischemic Events Aortic Injury Coronary Perforation Stent Misadventures

8. Northeast Georgia Heart Center Basis of Major Ischemic Complications Vessel Closure Distal Embolization Myocardial Infarction Ischemic LV Dysfunction Emergency CABG Death

9. 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 ●Edge dissections

10. Balloon Induced Dissection Treated Successfully with Stenting

11. Northeast Georgia Heart Center Retrograde Left Main Dissection Safian et al Treatment: CABG, emergency stent if unstable

12. Northeast Georgia Heart Center One Mechanism of Left Main Injury from Guide Manipulation

13. Northeast Georgia Heart Center Guide-Induced Left Main Injury Following LAD Stent

14. Northeast Georgia Heart Center Left Main Injury Treated with Stent Implantation

15. Embolic Consequences of PCI No Reflow Myocardial Necrosis

16. Northeast Georgia Heart Center

17. Northeast Georgia Heart Center 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

18. 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)

19. Patterns of Post-PCI Hyperenhancement Representing Focal Myo-necrosis Rarely Observed Adjacent To Stent Selvanayagam et al Circulation 2005;111:1027-1032

20. 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

21. 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%

22. Management of No Reflow – It’s not all Particulate Matter Avoid by using embolic protection when appropriate Support the patient (IABP if needed) Aspirate stagnant dye column Deliver microvascular dilators distally “pulse – spray” Sodium Nitroprusside or Calcium blocker – 50 to 100 mcg bolus Adenosine – 10 to 30 mcg doses (t½ < 20sec) 2 drugs is better than 1

23. 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

24. Northeast Georgia Heart Center Class 1 Dissection Into the Right Coronary Cusp Successfully Treated with Stent Implantation Dunning et al Cathet. Cardiovasc. Intervent. 51:387, 2000.

25. Northeast Georgia Heart Center Class 2 Dissection Extending Into the Aorta with RCA Occlusion Requiring CABG Dunning et al Cathet. Cardiovasc. Intervent. 51:387, 2000.

26. Northeast Georgia Heart Center Class 2 Dissection Above the RCA Treated Successfully with RCA Stent Dunning et al Cathet. Cardiovasc. Intervent. 51:387, 2000.

27. Class 3 Dissection Extending Into the Aortic Arch often with Fatal Outcome Dunning et al Cathet. Cardiovasc. Intervent. 51:387, 2000.

28. Northeast Georgia Heart Center Aortic Dissections Almost all are RCA dissections 4/9 cases were with Amplatz guide catheter Most occurred with STEMI patients Class 1 and 2 best treated with observation or stent placement Class 3 need surgery

29. 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

30. Coronary Perforation Classification Type 1Crater extending outside lumen only Type 2Pericardial or myocardial blush with < 1mm exit hole Type 3Contrast jet through > 1mm exit hole Type 4 Or Type 3 Cavity Splitting Perforation into anatomic cavity Ellis et al. Circulation 1994;90:2725

31. Type 2 Perforation

32. Northeast Georgia Heart Center Type 3 Perforation

33. Northeast Georgia Heart Center Type 3 Perforation

34. Northeast Georgia Heart Center Type 3 Perforation

35. Northeast Georgia Heart Center Type 3 Perforation

36. Northeast Georgia Heart Center Type 4 (or Type 3-CS) Perforation Connections between coronaries and cardiac structures LAD to LV RCA to RV Very Rare Best treated with covered stents

37. Causes of Coronary Perforation During PCI 1995-1999 at Christ Hospital (N = 6,214 PCIs) 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 for Ablative Rx OR = 6.8 [CI 3.4-13.7; P< 0.001]

38. Risk Associated with Type 3 Perforation Ellis et al. 1992Dippel et al. 2001 Tamponade63%43% Surgery75%50% QMI29% Death14%21%

39. 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

40. JoMed/Graft Master 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

41. Northeast Georgia Heart Center Small “Stain” Noted on the Inferior Wall During RCA Stent Procedure Reopro Discontinued

42. Northeast Georgia Heart Center Tamponade 3 hrs Later: Balloon Occlusion Sealed Perforation Only After Distal Platelet Injection

43. 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)

44. 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

45. Stent Maldeployment Imprecise placement Stent entrapment in uncrossable lesion Unexpandable lesion Sheared off by guide catheter Lost!

46. 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

47. Northeast Georgia Heart Center Common Mechanism of Stent Loss Brilakis et al CCI 2005;66:33 Stent Entrapment

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

49. Northeast Georgia Heart Center Retrieval of Stent with Loop Snare Brilakis et al CCI 2005;66:33

50. Northeast Georgia Heart Center Twisted Wire Stent Retrieval Brilakis et al CCI 2005;66:33

51. Northeast Georgia Heart Center Small Balloon Stent Retrieval Brilakis et al CCI 2005;66:33

52. Northeast Georgia Heart Center Retrieval Devices Brilakis et al CCI 2005;66:33

53. 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

54. 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

55. Conclusion ●As a young “attending” establish a team, get a senior mentor ●Don’t be afraid to call the calvary ●ALWAYS tell the patient EXACTLY what happened in “layman’s language”