1. 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

2. 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.
Affiliation/Financial Relationship Company
Consulting Fees/Honoraria None
Major Stock Shareholder/Equity None
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Other Financial Benefit None

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

4. 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

5. 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

6. 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:

7. 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%

8. 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

9. 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

10. 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

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

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

13. PCI of Chronic Total Occlusion
Difficult Wire Passage

14. Type 3 Perforation Following Inflation of 1.5mm Balloon

15. Type 3 Perforation Treated with Coil Embolization

16. 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)

17. 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

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

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

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

22. 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%

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

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

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

26. A 1.5X20 Balloon Was Inserted Inflated ,and Withdrawn

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 A 1.5X20 Balloon Was Inserted Inflated ,and Withdrawn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

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 A 1.5X20 Balloon Was Inserted Inflated ,and Withdrawn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

31. 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%

32. 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%

33. Retrieval Devices
Brilakis et al CCI 2005;66:33

41. Final RCA Result

42. 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

43. 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

44. 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