[Perforation and rupture of coronary arteries]

Evaluation of Biodegradable Stent Graft Coatings in Pig and Rabbit Models

AIMS

Percutaneous coronary intervention is routinely performed to treat occlusive coronary artery disease. Coronary perforation is a potential complication and can be treated with a stent graft. Current stent grafts are associated with high restenosis rates. We tested the safety and feasibility of biodegradable stent grafts in pig and rabbit models.

METHODS AND RESULTS

Stent grafts were examined in pig coronaries with repeated OCT imaging for 42 days. Novel biodegradable coatings were applied on a bare metal stent by either an electrospinning (ES) or dip coating (DC) method. A completely biodegradable system was made by ES coating a magnesium-based stent. A commercially available stent graft served as a control. ES devices showed less restenosis (44.3 ± 8.8 vs. 59.1 ± 11.1% in controls, p < 0.05) and smaller reduction in minimum lumen area (44.3 ± 13.4 vs. 64.4 ± 13.6% in controls, p < 0.05) at day 42. DC devices occluded during follow-up. ES devices showed recanalization through the graft wall at day 42. Feasibility of the ES and DC devices was evaluated in pig coronary aneurysms and rabbit aortic perforation models and sealed aneurysms and perforations without complications.

CONCLUSIONS

Recanalization of the graft wall improves biocompatibility. Biodegradable stent grafts may present an alternative to permanent implants by showing reduced restenosis at day 42.

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.

Fistula between right coronary artery vein graft and right atrium as an immediate complication of percutaneous coronary intervention

Fistula between saphenous vein graft (SVG) and a cardiac chamber or structure is a rare complication after coronary artery bypass grafting (CABG). We report the first case of a fistula between SVG and the right atrium (RA) as an immediate complication after a percutaneous coronary intervention (PCI) in an 86-year-old female. She presented with inferior ST-elevation myocardial infarction (STEMI) and was treated with thrombolytic therapy in a peripheral hospital, which was unsuccessful. PCI to SVG to the right coronary (RCA) was complicated by a fistula to RA. Cardiac magnetic resonance (CMR) confirmed the site of the fistula and also presence of a significant arteriovenous (AV) shunt. Reversal of anticoagulation had no effect on fistula closure. Therefore, a covered stent was deployed for closure of the fistula to avoid long-term complications of the significant AV shunt. In summary, the diagnosis and appropriate management of this rare complication is challenging, but excellent result can be achieved by the use of appropriate percutaneous techniques.

Dual catheter technique for the treatment of severe coronary artery perforations

OBJECTIVES

To evaluate the outcome of patients with coronary perforations who were treated with the dual catheter approach.

BACKGROUND

Coronary artery perforation is a grave complication of percutaneous coronary intervention (PCI) with high mortality and morbidity. Treating a coronary artery perforation with two catheters through dual access enables a rapid delivery of covered stent or coils to the vessel, without losing control of the perforation site.

METHODS

We retrospectively reviewed all patients who had a severe coronary perforation during a PCI in our center, and compared outcomes of patients treated with the dual versus the traditional single guiding catheter approach.

RESULTS

Between April 2004 and October 2008, 13,466 PCI's were performed in Columbia University - New York Presbyterian Medical Center. There were 33 documented cases of coronary perforations during that period of time (0.245%), among these, 26 were angiographically severe (Ellis type 2 or 3 perforations). Eleven patients were treated acutely with a dual catheter technique whereas the other fifteen patients were treated using a single guiding catheter. In the dual catheter group one patient expired after emergent CABG (9.1%), and four patients underwent emergent paricardiocentesis (36.4%). In patients treated with single catheter, there were three deaths (20%), two surgical explorations (13.3%), eight emergent pericardiocenthesis (53.3%), and one event of severe anoxic brain damage (6.7%).

CONCLUSION

The dual catheter technique is a relatively safe and reproducible approach to treat a PCI induced severe coronary artery perforation, and may improve outcome compared to historical series.

An iatrogenic coronary arteriovenous fistula causing a steal phenomenon: an intracoronary Doppler study

We present the case of a 67-year-old man in whom a guidewire broke at rotablation of the right coronary artery, creating an iatrogenic aneurysmal arteriovenous fistula to the coronary sinus. Successful Doppler wire-guided fistula occlusion by percutaneous coil embolization lead to normalization of coronary blood flow and relief of the patient's symptoms. Myocardial ischemia in this patient may have been due to a steal phenomenon caused by coronary artery fistulae, as suggested by blood flow velocity data obtained before and after fistula occlusion.

Treatment of coronary artery perforations complicating percutaneous coronary intervention with a polytetrafluoroethylene-covered stent graft

Coronary artery perforation is a rare, but dreaded, complication of percutaneous coronary intervention. Conventional treatment, including reversal of anticoagulation and prolonged balloon inflation, is associated with a high incidence of death, Q-wave myocardial infarction, and emergency coronary bypass surgery. Although a number of case reports have demonstrated the feasibility of sealing coronary perforations with synthetic material-covered stent grafts, the efficacy of this treatment has not been reported in a large, multicenter series. We used a retrospective international registry to examine the outcomes of the polytetrafluoroethylene-coated JOSTENT coronary stent graft (CSG) in 41 cases of coronary perforations. Perforations were relatively severe: 16.7% Ellis grade 1, 54.2% grade 2, and 29.1% grade 3. Of the 41 patients, > 1/3 (n = 14) experienced life-threatening complications before stent graft implantation, including pericardial tamponade (12.2%), cardiogenic shock (9.8%), and cardiac arrest (2.4%). A total of 52 CSGs were used to treat the 41 perforations (mean 1.3 per lesion). All CSGs were placed successfully, with 92.9% of the perforations sealed completely and 7.1% partially. One patient developed abrupt vessel closure after CSG deployment, resulting in an overall procedure success rate of 96.4%. No in-hospital Q-wave myocardial infarctions, emergency coronary bypass surgeries, or deaths resulted. The CSG may be a reliable and highly effective treatment option for sealing coronary perforations complicating percutaneous coronary interventions.

Compression of right ventricular out-flow due to localized hematoma after coronary perforation during PCI

Although coronary perforation can cause tamponade during percutaneous coronary intervention (PCI), this is unusual for patients previously undergoing coronary artery bypass graft surgery (CABG) due to pericardial adhesions. We report here on a rare case of right ventricular out-flow obstruction complicating PCI in a patient with a previous CABG.

Results of the Jostent coronary stent graft implantation in various clinical settings: procedural and follow-up results

The Jostent coronary stent graft (CSG) is composed of a PTFE layer sandwiched between two stainless steel stents, initially introduced for the treatment of coronary perforations and aneurysms with excellent results. By providing a mechanical barrier, this stent design also may be beneficial in the treatment of complex ulcerated lesions and in-stent restenosis by preventing debris protrusion and neointimal proliferation through the stent struts. To evaluate the safety and efficacy of this stent graft, we implanted 78 CSGs in 70 patients for a broad range of indications, including coronary perforations, aneurysms, degenerated saphenous vein grafts, complex lesions, and in-stent restenosis. The primary angiographic success rate (95.9%) was high, and using intravascular ultrasound (IVUS) guidance during stent implantation and high inflation pressures (19.3 +/- 3.2 atm), stent expansion with optimal symmetry was achieved in 94.7%. One limitation of the Jostent CSG was the side-branch occlusion rate (18.6%) and the resulting non-Q-wave infarction rate in seven cases (mean CK elevation, 238 U/l), acute Q-wave MI in two cases, and transient ventricular fibrillation in one patient after occlusion of the proximal RCA side branch without further complications. Subacute stent thrombosis occurred in four cases (5.7%) 7 to 70 days after stent implantation, despite using combined antiplatelet therapy with aspirin (ASA), ticlopidine, and/or clopidogrel for 30 days. Angiographic follow-up was available in 56 patients (80.0%) after a mean of 159 +/- 49 days, and follow-up IVUS was available in 38 cases. The overall restenosis rate (> 50% diameter stenosis) was 31.6% manifest primarily as edge restenosis (29.8% stent edge vs. 8.8% stent center; P < 0.001). IVUS examinations showed a minimal late lumen loss of 0.4 +/- 2.2 mm(2) within the center of the stent graft vs. 3.2 +/- 2.3 mm(2) at the stent edges (P < 0.001). The restenosis rate in the prespecified subgroups was 33.3% for saphenous vein grafts (2/6 lesions), 30.0% in complex lesions (6/20 lesions), and 38.5% (10/26 lesions) for the treatment of in-stent restenosis. Implantation of the Jostent CSG is feasible and safe, even in complex lesion subsets, and is associated with high primary success rates provided major side branches are avoided. The use of this stent may require an extended time course of antiplatelet therapy. Frequent focal stent edge renarrowing influences the overall restenosis rate. However, in treatment of complex in-stent restenosis and vein graft lesions, stent grafts may offer benefit over conventional therapies. Covered stents such as the JoMed coronary stent graft may become essential for bailout treatment of coronary perforations.

Successful management of coronary artery perforation with helical platinum microcoil embolization

A case of small coronary artery perforation during coronary intervention is presented. Continued leakage occurred despite prolonged intracoronary balloon inflation, in part probably related to the use of glycoprotein (GP) IIB/IIIA inhibitors. It was successfully managed by microcoil embolization without any sequel, helping avoid surgery in a high-risk patient. Cathet. Cardiovasc. Intervent. 51:320-322, 2000.

Coronary stent grafts covered by a polytetrafluoroethylene membrane

In a prospective observational study, 40 patients were treated with coronary stent grafts covered by a polytetrafluoroethylene membrane. These devices may be regarded as therapy of choice for acute coronary rupture; treatment of conventional in-stent restenosis was not associated with a favorable outcome, whereas the promising results in degenerated vein grafts warrant a randomized, controlled trial.