Salvage of Simultaneous Acute Coronary Closure and Retroperitoneal Bleeding Using Veno-Arterial Extracorporeal Membrane Oxygenation and Chronic Total Occlusion Percutaneous Coronary Intervention Techniques in a Patient with ST-Segment Elevation Myocardial Infarction

Incidence, mechanisms, treatment, and outcomes of donor vessel injury during percutaneous coronary interventions for chronic total occlusion

BACKGROUND

Donor vessel injury is a potentially life-threatening complication of chronic total occlusion (CTO) percutaneous coronary intervention (PCI).

AIMS

Our goal was to examine the incidence, mechanisms, treatment, and outcomes of patients with donor vessel injury in a large multicenter CTO PCI registry.

METHODS

We analyzed the baseline clinical and angiographic characteristics, and procedural outcomes of 12,349 CTO PCIs performed between 2012 and 2022 at 44 centers.

RESULTS

The incidence of donor vessel injury was 0.35% (n = 43). The baseline clinical characteristics of patients with and without donor vessel injury were similar. Cases complicated by donor vessel injury were more complex with higher Japanese CTO score (2.9 ± 1.1 vs. 2.4 ± 1.3; p = 0.004) and lower procedural success rate (69.8% vs. 85.2%; p = 0.004). The retrograde approach was used more commonly in donor vessel injury cases (68.9% vs. 30.9%; p < 0.001). Most (53.5%) donor vessel injuries were guide catheter-induced, whereas 20.9% were due to donor vessel thrombosis. Of the 43 patients with donor vessel injury, 36 (83.7%) were treated with stenting and seven (16.3%) received a left ventricular assist device. The incidence of major adverse cardiovascular events (MACEs) was significantly higher in cases with donor vessel injury (23.3% vs. 2.0%; p < 0.001). Of the 43 patients with donor vessel injury, five patients (11.6%) experienced acute myocardial infarction and four patients (9.3%) died.

CONCLUSIONS

Donor vessel injury, occurred in 0.35% of CTO PCIs performed by experienced operators, was mainly due to guide catheter-induced dissection or thrombosis and was associated with lower procedural success and higher MACE.

Chronic total occlusion recanalization for myocardial infarction

An 84-year-old patient with prior coronary artery bypass surgery presented with non-ST segment elevation acute myocardial infarction. The culprit lesion was at the distal anastomosis of a saphenous vein graft (SVG) to the right posterior descending artery. The proximal right coronary artery was chronically occluded. Because of significant disease both proximal and distal to the SVG anastomosis, percutaneous intervention of the SVG carried high risk for acute vessel closure. The native right coronary artery chronic total occlusion was successfully recanalized, enabling complete revascularization of the right coronary artery. The SVG was then occluded using an Amplatzer vascular plug.