Global Consensus Recommendations on Improving the Safety of Chronic Total Occlusion Interventions

Safety is of critical importance to chronic total occlusion (CTO) percutaneous coronary intervention (PCI). This global consensus statement provides guidance on how to optimise the safety of CTO) PCI, addressing the following 12 areas: 1. Set-up for safe CTO PCI; 2. Guide catheter--associated vessel injuries; 3. Hydraulic dissection, extraplaque haematoma expansion, and aortic dissections; 4. Haemodynamic collapse during CTO PCI; 5. Side branch occlusion; 6. Perforations; 7. Equipment entrapment; 8. Vascular access considerations; 9. Contrast-induced acute kidney injury; 10. Radiation injury; 11 When to stop; and, 12. Proctorship. This statement complements the global CTO crossing algorithm; by advising how to prevent and deal with complications, this statement aims to facilitate clinical practice, research, and education relating to CTO PCI.

Coronary perforation complicating percutaneous coronary intervention in patients presenting with an acute coronary syndrome: An analysis of 1013 perforation cases from the British Cardiovascular Intervention Society database

BACKGROUND

The evidence base for coronary perforation occurring during percutaneous coronary intervention in patients presenting with an acute coronary syndrome (ACS-PCI) is limited and the specific role of acute pharmacology in its clinical presentation unclear.

METHODS AND RESULTS

Using the BCIS PCI database, data were analysed on all ACS-PCI procedures performed in England and Wales between 2007 and 2014. Multiple regressions were used to identify predictors of coronary perforation and its association with outcomes. Propensity score matching was used to evaluate the association between differing P2Y12 inhibitors or glycoprotein inhibitors (GPI) and CP. During 270,329 ACS-PCI procedures, 1013 coronary perforations were recorded (0.37%) with a stable annual incidence. In multiple regression analysis, covariates associated with increased frequency of coronary perforation included age, female gender, CTO intervention, number and length of stents used, and rotational atherectomy use, whilst differing P2Y12 inhibitors were not predictive. Using propensity score matching, use of a GPI was independently associated with tamponade (OR 1.50, [1.08-2.06], p = 0.014). The adjusted odds ratios for all clinical outcomes were adversely affected by coronary perforation.

CONCLUSIONS

Coronary perforation is an infrequent event during ACS-PCI but is closely associated with adverse clinical outcomes. GPI use was associated with higher rates of tamponade.

Graftmaster savior: Injury to a patent LIMA during pericardiectomy, when a covered stent came to the rescue

A 71-year-old male with multivessel coronary artery disease who underwent bypass with saphenous vein grafts to a Marginal branch and distal RCA and LIMA to LAD in 1988, DM II, atrial fibrillation on Coumadin, TIA, obstructive sleep apnea and pulmonary hypertension was referred to our institution after extensive dyspnea evaluation with a diagnosis of constrictive pericarditis for pericardiectomy. He had normal left ventricular function, moderate mitral and tricuspid regurgitation. Coronary angiography revealed ostial LAD CTO, patent LIMA to mid LAD, second Marginal branch CTO with left-to-left collaterals and mid RCA CTO with left-to-right collaterals. Vein grafts to the Marginal branch and distal RCA were occluded. The pericardium was heavily calcified on CT of the chest. The LIMA was inadvertently injured leading to acute STEMI and ventricular fibrillation arrest treated with defibrillation once. Surgical repair was unsuccessful. A Graftmaster covered stent was successful deployed with restoration of TIMI III flow to the LAD territory. Pericardiectomy was completed via both the median resternotomy and left thoracotomy. Triple therapy with Aspirin, Clopidogrel, and Coumadin was initiated and maintained for 3 months without hemorrhagic or thrombotic complications. He has continued to do well in follow-up on Clopidogrel and Coumadin.

Perforation of a Saphenous Vein Graft Anastomosed at a Y-Configuration to the Left Internal Mammary Artery

Perforation of a saphenous vein graft (SVG) is a rare, yet dreadful complication during percutaneous coronary intervention (PCI). Perforation of a SVG arising at a Y-construction from the left internal mammary artery (LIMA) can be catastrophic since manipulations and material delivery through the single LIMA inflow can aggravate ischemia and accelerate hemodynamic collapse. Prior CABG and pericardial obliteration should not offer reassurance against tamponade, since coronary perforation in these patients may cause the development of loculated pericardial effusions, a complication associated with high mortality. Treating physicians must be alert for potential periprocedural pitfalls during PCI in post-CABG patients and these should be taken into consideration during interventional planning, procedure and follow-up.

Chronic Total Occlusion Interventions: Update on Current Tips and Tricks

PURPOSE OF REVIEW

To summarize novel techniques and developments in chronic total occlusion (CTO) percutaneous coronary intervention (PCI).

RECENT FINDINGS

Using an algorithmic, step-by-step approach can help overcome several complex CTO lesions subsets, such as proximal cap ambiguity, ostial location, in-stent occlusion, bifurcations, balloon uncrossable and undilatable lesions. Similarly, an algorithmic approach can help prevent and optimally treat CTO PCI-related complication, such as perforation, radiation, and contrast-induced nephropathy. Continual update and reassessment of each operator's algorithm for performing CTO PCI can lead to improved outcomes.

Treatment and outcome of coronary artery perforations using a dual guiding catheter technique

OBJECTIVES

To evaluate the success rate and outcome of coronary artery perforation treatment using a dual guiding catheter technique.

BACKGROUND

Coronary artery perforation is a rare but severe complication during percutaneous coronary intervention (PCI) with high mortality. The use of a second guiding catheter is a helpful technique to minimize hemorrhage through the perforation during interventional repair.

METHODS

We screened all patients between March 2004 and December 2014 who underwent PCI in our department for the occurrence of peri-interventional coronary perforation that was treated using a dual catheter technique. Patient and lesion characteristics as well as outcome were determined.

RESULTS

We identified 8 patients who experienced coronary artery perforations (Ellis grade III) during coronary intervention and were treated using a dual guiding catheter approach. The procedure was technically successful (placement of covered stent and sealing of perforation) in 6 patients. Pericardiocentesis was required in 3 patients (38%). Total mortality was 12% (n=1). No coronary or peripheral vascular access complication occurred due to the use of a second guiding catheter.

CONCLUSIONS

We suggest that the dual guiding catheter technique is a useful and alternative approach to treat severe Ellis grade III coronary artery perforations that occur in the context of percutaneous coronary interventions.

Coronary bypass graft perforation during percutaneous intervention

INTRODUCTION

Coronary artery bypass grafts are prone to accelerated atherosclerosis and as such graft stenosis is frequently encountered in clinical practice. Complications specific to graft- PCI include no-reflow, distal embolization, stent restenosis and thrombosis. Graft perforation during PCI is a rare coomplication of the procedure. Published literature on the predictors of perforation and management strategy remains limited to anecdotal cases.

METHOD

In this review we collected data on all cases of graft perforations reported in PubMed/Medline from 1987 to 2015.

RESULT

37 cases of graft perforation were reported. High risk grafts for perforations included, old grafts (14±7.8years) with more than 80% luminal stenosis. Perforations were noted after use of different cardiac devices and included stent placement (30%, N=11), balloon angioplasty (36%, N=14), post-dilation with non complaint balloon (16%, N=6), guide wire perforation (1 case), post IVUS imaging (1 case) and one case after use of thrombus extraction device. Average stent diameter of 3.7±0.7 mm, average balloon pressure of 15.5±5 atm and 3 or more balloon inflations commonly resulted in graft perforation. 78% of cases reported class III perforation. Covered stent implantation was strongly associated with controlling acute bleed after graft perforation than prolonged balloon inflation (p=0.0001). Majority of cases reported using covered stents (81%). Average stent diameter of 3.9±0.7mm, average stent length of 18.5±6mm and the average deployment pressure of 14±2atm were reported to be effective in controlling the bleed. 95% of the patients did well post procedure and with prolonged hospitalization (8±4days). 24% of cases reported cardiac tamponade causing hemodynamic compromise including 2 peri-procedural deaths.

CONCLUSION

Graft perforation can be effectively treated with covered stent grafts with good immediate results, short term outcome and acceptable peri-procedural risks.

Immediate and Long-Term Results of Drug-Eluting Stents in Mammary Artery Grafts

Percutaneous intervention of a coronary graft is the treatment of choice when the graft fails. The objective is to report the long-term results of drug-eluting stents (DES) in mammary artery grafts (MAG). Patients who had been treated with DES for MAG in 27 centers were selected. The baseline and procedural clinical data were included prospectively, and the follow-up was performed with the patients, families, and medical records. Two hundred and sixty-eight patients were included: age 65.5 ± 10.1 years, diabetes 47.8%, ejection fraction 55.5 ± 14.9%.

INDICATION

stable angina 28.4%, unstable angina 38.1%, non-ST-elevation myocardial infarction 21.6%, ST-elevation myocardial infarction 5.3%, and heart failure 6.7%; 1.19 ± 0.59 stents/patient were implanted measuring 18.8 ± 8.8 mm in length and 2.68 ± 0.35 mm in diameter. Rapamycin was used in 78 cases (29.1%), paclitaxel in 77 (28.7%), everolimus in 70 (26.1%), zotarolimus in 34 (12.7%), and biolimus in 9 (3.4%). All cases were successful except for 1 in which the patient died 30 minutes after the procedure. There were no other inhospital events. After a follow-up of 41 months (Q25: 23.7 to Q75: 57.8), 24 patients (9%) died of heart-related causes and 20 (7.5%) of noncardiac causes. Repeat revascularization was necessary in 31 cases, and in 1 additional patient, there was total occlusion, which was not treated. These 32 patients represented 11.9% of the total. In conclusion, the implantation of DES in MAG shows very high procedural success and also low long-term event rates.