Guidewire-induced coronary artery perforation treated with transcatheter injection of polyvinyl alcohol form

Chronic total occlusion percutaneous coronary intervention: managing perforation complications

INTRODUCTION

Coronary artery perforation (CAP) is an infrequent (<1%) complication of percutaneous coronary intervention (PCI), that can lead to dramatic consequences, including tamponade and death. The incidence of CAP is higher (4-9%) in chronic total occlusion (CTO) PCI due higher complexity of these lesions and the techniques used to recanalized them.

AREAS COVERED

In this Expert Review, we discuss the specific features of CTO PCI predisposing to CAP. We also describe the typical procedural scenarios in which CAP can occur and provide a universal management algorithm. Currently available devices and techniques for CAP treatment are presented in detail. Finally, we discuss imaging support for diagnosis of pericardial effusion in CAP as well as medical and surgical management.

EXPERT OPINION

With increasing volumes and complexity of CTO PCI, the incidence of CAP is likely to rise. Adherence to good catheterization laboratory practices, availability of dedicated equipment to seal CAP, perform pericardiocentesis, and provide hemodynamic support, as well as adequate training, are pillars for the prevention and optimal management of CAP during CTO PCI.

Coronary Perforation Complicating Percutaneous Coronary Intervention - A Case Illustration and Review

Coronary perforation is a potentially fatal complication during percutaneous coronary intervention (PCI). Reports have shown that it occurs in 0.2 to 0.6% of all patients undergoing the procedures. [1-3] Though the frequency of coronary perforation is low, it is a serious and potentially life-threatening situation that warrants prompt recognition and management. Here we illustrate a case of coronary perforation, and review the incidence, causes, clinical sequelae and management of coronary perforation in the current contemporary practice.

A unique and unexplained ricochet leak post PCI - successfully treated with intra-coronary glue

We herein describe a unique case of coronary artery perforation treated with covered stent with repeat cardiac tamponade resulting out of a fresh unexplained leak from a remote vessel (Ricochet) and successfully treated with intra-coronary injection of sterile synthetic glue, cyanoacrylate.

Renal artery perforation related with hydrophilic guide wire during coronary intervention: successful treatment with polyvinyl alcohol injection

Hydrophilic guide wire-related renal artery perforation (RAP) and subsequent retroperitoneal hemorrhage (RPH) during coronary angiography (CAG) is very rare. We present the case of a 68-year-old woman who suffered accidental hydrophilic 0.035-inch guide wire piercing-related RAP and RPH during CAG and coronary intervention. This RAP was diagnosed by bedside ultrasonography and selective renal angiography, and was successfully treated by transcatheter polyvinyl alcohol injection.

Intracoronary thrombin injection using a microcatheter to treat guidewire-induced coronary artery perforation

Coronary artery perforation (CAP) is an infrequent yet a very dangerous complication of percutaneous coronary intervention. We describe the successful treatment of a guidewire-induced distal coronary branch vessel perforation using localized distal injection of intracoronary thrombin with a microcatheter. This technique appears to be safe and effective for the treatment of life-threatening distal guidewire perforations, even in the smallest tertiary coronary branches.

Foreign body granulomatous change from absorbable gelatin sponge and microcoil embolization after a guidewire-induced perforation in the distal coronary artery

We report an autopsy case of treatment by absorbable gelatin sponge and microcoil embolization after perforation of the distal coronary artery by guidewire. Histological examination revealed a foreign body granuloma in the coronary artery with embolization. Foreign body reaction to absorbable gelatin sponge seemed to be stronger than that to the microcoil.

Collagen embolization for the successful treatment of a distal coronary artery perforation

A 42-year old man suffered a coronary artery perforation in the right coronary artery secondary to a hydrophilic guidewire. We describe for the first time the use of collagen embolization to successfully treat this complication.

A unique complication of the retrograde approach in angioplasty for chronic total occlusion of the coronary artery

The retrograde approach for chronic total occlusion of coronary arteries is a new treatment strategy, although its attendant complications have not yet been fully appreciated. We report a case of isolated left ventricular cardiac tamponade caused by guidewire-induced perforation of the septal branch during the retrograde approach, which was subsequently diagnosed by computed tomography (CT) and which required surgical drainage. Guidewire-induced perforation of the septal branch was successfully treated by autologous subcutaneous tissue embolization of the perforated coronary artery. This is the first case of its kind to date.

Coronary artery perforation successfully treated with tris-acryl gelatin microsphere embolisation

We describe a case of coronary artery perforation in a 76-year-old man, successfully treated by tris-acryl gelatin microsphere embolisation. This novel interventional embolic material is used in interventional radiology for arterial embolisation. We believe that this is the first report of its use for a coronary artery perforation.

Closure of guide wire-induced coronary artery perforation with a two-component fibrin glue

Perforation or rupture of a coronary artery with subsequent pericardial effusion and cardiac tamponade is a potentially life-threatening complication of percutaneous coronary intervention (PCI). Several emergency treatment strategies exist to close the perforation including reversal of anticoagulation, prolonged balloon inflation, implantation of stent grafts, local injection of thrombogenic molecules, placement of microcoils, or open heart surgery. Here we report on a 66-year-old patient who underwent urgent PCI for acute stent thrombosis in the proximal LAD. The artery was reopened, a new stent implanted successfully, and a GPIIb/IIIa-antagonist was given. Shortly thereafter the patient suffered from cardiac tamponade requiring pericardiocentesis and pericardial drainage. The coronary angiogram indicated a severe guide wire-induced perforation and pericardial effusion originating from a distal diagonal branch segment. Prolonged balloon inflation did not stop the leakage. Therefore the monorail balloon was exchanged for an over-the-wire balloon. A two-component commercial fibrin glue consisting of fibrinogen and thrombin was rapidly but separately injected through the wire channel of the balloon into the distal segment of the diagonal branch. The coronary leak was successfully closed and the patient recovered quickly. In comparison with the previously reported cases of thrombin injection important differences should be noticed: (1) a two-component hemostatic seal was used without reversal of anticoagulation, (2) rapid injection instead of prolonged infusion of the hemostatic drugs was performed, and (3) the rescue technique was applied in a cath lab that routinely uses monorail catheter systems. Therefore we consider this a novel and effective approach for closure of coronary ruptures.

Guidewire-induced coronary artery perforation treated with transcatheter delivery of subcutaneous tissue

In three cases of small coronary artery perforation by guidewires during percutaneous coronary intervention, coronary leakage continued despite prolonged balloon inflation and reversal of heparin. Subcutaneous tissue was selectively delivered to perforated vessels by means of microcatheters in a successful attempt to stop leakage. This method appears to be extremely effective for treating guidewire-induced perforations of distal coronary arteries.

Endovascular treatment of a massive retroperitoneal bleeding: Successful balloon-catheter delivery of intra-arterial thrombin

Retroperitoneal bleeding is a potentially lethal complication of percutaneous intervention, when the common femoral artery is used as vascular access. Surgery, the traditional treatment for this complication in patients with persistent bleeding or hemodynamic instability, carries a considerable risk of morbidity and mortality. We report a case of life-threatening retroperitoneal bleeding successfully treated percutaneously with balloon occlusion and catheter delivery of thrombin to attain thrombosis of a lacerated branch of the common femoral artery. Endovascular catheter-based percutaneous treatment for massive retroperitoneal bleeding is often effective and should be pursued in selected patients.

Pseudoperforation during kissing balloon angioplasty

We describe a case of apparent perforation during kissing balloon angioplasty of a bifurcation lesion. There was no evidence of perforation on follow-up angiography or via intravascular ultrasound. Possible etiologies include minimal perforation that immediately sealed postdeflation or forced contrast into the microvascular bed via a proximal side branch.

Successful treatment of distal coronary guidewire-induced perforation with balloon catheter delivery of intracoronary thrombin

Distal coronary artery perforation with a coronary guidewire is a relatively rare but potentially fatal complication during PTCA. Historically, these types of perforations have been easy to control with reversal of heparin anticoagulation combined with prolonged distal balloon inflation. In the modern era, with widespread use of potent glycoprotein IIb/IIIa inhibitors, this type of distal wire perforation has become more difficult to manage and potentially lethal. In this article, we report two cases of guidewire-related distal coronary artery perforation, successfully treated using a new technique using localized, distal intracoronary thrombin injection. During prolonged low-pressure balloon inflation, a small dose of thrombin was injected just proximal to the wire perforation site via the lumen of a coronary balloon catheter. This approach appears to be a relatively rapid and effective way to control this troublesome complication.