Transcript Slide 1
Complications of Percutaneous Coronary Intervention
SCAI International Fellows Course 2012 November 20, 2012 1:20PM John S. Douglas Jr. MD Professor of Medicine Emory University School of Medicine
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 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
Complications of PCI
The Basics Prevention Recognition Management
Complications of Percutaneous Coronary Intervention
• Ischemic Events • Stent Misadventures • Aortic Injury • Coronary Perforation
Basis of Major Ischemic Complications
Vessel Closure Distal Embolization • Myocardial Infarction • Ischemic LV Dysfunction • Emergency CABG • Death
Emergent CABG in 41 Patients During 5875 PCI (0.7%) 1995-2000
Reasons For CABG
Dissection Maldeployed Stent Perforation Wire Failure Clot Etc
Hopkins et al CCI 2001;53:99
Emergency Bypass Surgery 1979-2003
N= 23,087 Yang et al J Am Coll Cardiol 2005; 46: 2004
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
Retrograde Left Main Dissection
Treatment: CABG, emergency stent if unstable Safian et al
Common Mechanism of Left Main Injury from Left Amplatz Guide
Left Main Injury Following LAD Stent
Left Main Injury Treated with Stent Implantation
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
Class 1 Dissection Into the Right Coronary Cusp Successfully Treated with Stent Implantation
Dunning et al Cathet. Cardiovasc. Intervent. 51:387, 2000.
Class 2 Dissection Above the RCA Treated Successfully with RCA Stent
Class 3 Dissection Extending Into the Aortic Arch with Fatal Outcome
Dunning et al Cathet. Cardiovasc. Intervent. 51:387, 2000.
Embolic Consequences of PCI
• No Reflow • Myocardial Necrosis
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
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)
Correlation between troponin I and mass of hyperenhancement (amount of irreversible injury) Stent length correlated with injury (P=0.04) Selvanayagam et al Circulation 2005;111:1027-1032
Patterns of Post-PCI Hyperenhancement Representing Focal Myo-necrosis
Rarely Observed Adjacent To Stent
Selvanayagam et al Circulation 2005;111:1027-1032
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
SAFER Trial – Comparison of PercuSurge to Routine Stenting in SVG’s
801 Patients Randomized 20 %
30 Day MACE
16.5% Reduced 42% P<0.001
9.6% 0 Routine Baim et al. Circulation 2002; 105: 1285.
PercuSurge
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)
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)
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
0 Perforation Death J Am Coll Cardiol 1999; 33, 72A
Coronary Perforation Classification
Type 1 Type 2 Type 3 Crater extending outside lumen only Pericardial or myocardial blush without > 1mm exit hole Contrast jet through > 1mm exit hole Ellis et al. Circulation 1992; 88: I-787
Type 2 Perforation Following Stent Implantation
Type 2 Perforation Following Prolonged Balloon Inflation
Causes of Coronary Perforation During PCI 1995-1999 at Christ Hospital
36 Perforations 15 Odds Ratio Perf. 16 Type 3 Perf. 29 10 5 0 Guide Wire Balloon Stent Rotablater DCA Dippel et al. Cathet Cardiovasc Intervent 2001; 52:279-286 Laser/TEC
Risk associated with Type 3 Perforation
Tamponade Surgery QMI Death
Ellis et al. 1992
63% 75% 29% 14%
Dippel et al. 2001
43% 50% 21%
Cardiac Tamponade Complicating PCI – An 8 year experience at William Beaumont Hospital 36 Patients 60 56 44 42 39 % 29 0 In-Lab Out-of-Lab
(mean 5 hours)
Surgery MI
Fejka et al. Circulation 2001; 104: II-417
Death
JoMed PTFE Covered Stent for PCI Perforations Multicenter Study of 35 Patients Pericardial effusions Tamponade Complete Sealing Q Wave MI Emergency Surgery Death 22% 14% 100% 0 0 0
Lansky et al. JACC 2000; 35: 26A
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 -
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Angiographic (blush, jet, coronary sinus compression, contrast in pericardium)
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No angiographic evidence in 10-20%
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ECHO (Not needed in 50% at Beaumont)
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Delayed tamponade common (wire induced & IIbIIIa)
Management of Coronary Perforation Hemodynamic Support
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Volume and inotropes
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Pericardiocentesis (pigtail) IABP (to resussitate) Seal Perforation
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Reverse heparin
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Balloon occlusion Platelets (abciximab)
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Embolization (coil, gel foam, thrombus) Covered stent (Jomed available) Surgery
Stent Maldeployment
• Imprecise placement • Stent entrapment in uncrossable lesion • Unexpandable lesion • Sheared off by guide catheter • Lost!
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, abrupt closure, perforation, atherothromboembolization and stent regret continue to challenge the interventionalist.
● Attention to prevention, recognition and treatment of these complications is essential