Emmanouil S. Brilakis - Complications – how to manage

Complications – how to manage

EuroCTO Club

October 1, 2016

Emmanouil S. Brilakis, MD, PhD

Minneapolis Heart Institute

Adj. Professor of Medicine, UT Southwestern

1.30-1.45 pm

ES Brilakis: Disclosures

Consulting/speaker honoraria: Abbott

Vascular, Asahi, Cardinal Health, CTI,

Elsevier, GE Healthcare, St Jude

Medical

Employment (spouse): Medtronic

Grants: InfraRedx, Boston Scientific

VA - I01-CX000787-01

VA CSP#571 – DIVA

CORONARY

1. Vessel closes

• Dissection

• Embolization

• Spasm

• Pseudolesion

2. Vessel Leaks

• Perforation

3. “Wrong place”

• Equipment loss

PCI complications: a classification

HEART

1. MI

2. Arrhythmia -

arrest

3. Tamponade

OTHER

1. Access

2. Thromboembolic

3. Contrast

• Nephropathy

• Allergies

4. Radiation

CORONARY

1. Vessel closes

• Dissection

• Embolization

• Spasm

• Pseudolesion

2. Vessel Leaks

• Perforation

3. “Wrong place”

• Equipment loss

PCI complications: a classification

HEART

1. MI

2. Arrhythmia -

arrest

3. Tamponade

OTHER

1. Access

2. Thromboembolic

3. Contrast

• Nephropathy

• Allergies

4. Radiation

RCA CTO

Dual

injection

Crossing

confirmation

True to true

crossing

into aorta

Viper snared

and

externalized

Chest pain

and

hypotension

Lesson

Donor vessel

occlusion can be a

lethal event!

LAD wiring

and balloon

Stent placed in

LAD over

retrograde

guidewire

(microcatheter

removed)

Proximal

RCA stent

LAD?

Retrograde

microcatheter

to free wire

Retrograde

wire out!

Final LAD

Septal

hematoma

Procedure time: 7h 20min

Fluroscopy time: 118 min

AK dose: 11.2 Gray

Contrast: 1,430 ml

CORONARY

1. Vessel closes

• Dissection

• Embolization

• Spasm

• Pseudolesion

2. Vessel Leaks

• Perforation

3. “Wrong place”

• Equipment loss

PCI complications: a classification

HEART

1. MI

2. Arrhythmia -

arrest

3. Tamponade

OTHER

1. Access

2. Thromboembolic

3. Contrast

• Nephropathy

• Allergies

4. Radiation

Types of coronary perforation

Main Vessel

perforation

Distal Wire

perforation

Collateral

perforation

LAD CTO

AWE

Fielder XT

Wiring

confirmed

Predilation

– balloon

rupture

Lesson

Balloon rupture can

cause perforation

NOW

WHAT??

Perforation management

1. Inflate balloon to occlude vessel

2. Stat echo – pericardiocentesis

Stop

bleeding

Perforation management

1. Inflate balloon to occlude vessel

2. Stat echo – pericardiocentesis

Autotransfuse

Type + cross

Call surgeons

Perforation management

yes

1. Inflate balloon to occlude vessel

Monitor pt Treat the cause

no

Persistent extravasation?

2. Stat echo – pericardiocentesis

Autotransfuse

Type + cross

Call surgeons

Perforation management

yes

1. Inflate balloon to occlude vessel

Monitor pt

Large vessel

perforation

Contralateral access

Covered stent

Treat the cause

no

Persistent extravasation?

2. Stat echo – pericardiocentesis

Distal vessel wire

perforation

embolization or

suction

Autotransfuse

Type + cross

Call surgeons

Brilakis ES. Manual of coronary CTO interventions. Elsevier 2013

Large vessel perforation management 2

Brilakis ES. Manual of coronary CTO interventions. Elsevier 2013

Large vessel perforation management 3

Ping-pong

Lesson

Second guide can minimize

duration of pericardial

bleeding

Graftmaster Rx

• HDE - IRB approval needed

• 2.8 - 4.0 mm stents: 6 French guide

• 4.5 and 4.8 mm stents: 7 French guide

Papyrus

Unable to

deliver

2.80x19 mm

Graftmaster

6 Fr

Guideliner

Guideliner

and balloon

Covered

stent

through

Guideliner

Perforation

sealed

TTE

Lesson

With early treatment of perforation

tamponade can be avoided

After stents

ACT=227

Lesson

Bleeding can be

followed by thrombosis

Export

catheter

Final result

TTE at the end

1. Balloon rupture can be bad!

2. Large vessel perforation –

immediate sealing to prevent

tamponade

3. Ping-pong technique

4. Covered stents

5. Bleeding and thrombosis:

delicate balance

Conclusions

Perforation management

yes

1. Inflate balloon to occlude vessel

Monitor pt

Large vessel

perforation

Contralateral access

Covered stent

Treat the cause

no

Persistent extravasation?

2. Stat echo – pericardiocentesis

Reverse anticoagulation

Distal vessel wire

perforation

embolization or

suction

continued extravasation?

Autotransfuse

Type + cross

Call surgeons

Types of coronary perforation

Main Vessel

perforation

Distal Vessel

perforation

Collateral

perforation

RCA CTO

STAR

After

balloon

Different

view

Lesson:

Accept the facts –

FAST!

Lesson

Watch your wire!

Replace polymer

wires with

workhorse after

crossing

Perforation management

1. Inflate balloon to occlude vessel

2. Stat echo – pericardiocentesis

“Block and deliver”

Perforation management

yes

1. Inflate balloon to occlude vessel

Monitor pt

Large vessel

perforation

Contralateral access

Covered stent

Treat the cause

no

Persistent extravasation?

2. Stat echo – pericardiocentesis

Distal vessel wire

perforation

embolization or

suction

Autotransfuse

Type + cross

Call surgeons

Brilakis ES. Manual of coronary CTO interventions. Elsevier 2013

Distal vessel perforation management 1

Distal vessel perforation management 2

Brilakis ES. Manual of coronary CTO interventions. Elsevier 2013

Distal perforation treatment

1. Fat

2. Coil

3. Aspiration through microcatheter

4. Thrombus

5. Micro-beads

6. Thrombin

7. ??

A C

B D

Lesson

Fat floats!

Currently used coils in our lab

Axium – ev3 Azur – Terumo

Finecross 1.8 Fr Progreat 2.8 Fr

Block +

Deliver

Coil 1

Lesson:

Don’t push out coils

with the back end of

a wire!

Coil 2

Coil 3

Bleeding

continues

Bleeding

stopped

(finally…)

Perforation management

yes

1. Inflate balloon to occlude vessel

Monitor pt

Large vessel

perforation

Contralateral access

Covered stent

Treat the cause

no

Persistent extravasation?

2. Stat echo – pericardiocentesis

Reverse anticoagulation

Distal vessel wire

perforation

embolization or

suction

continued extravasation?

Autotransfuse

Type + cross

Call surgeons

Lesson:

Contrast echo to

ensure pericardial

bleeding has stopped

1. Block + Deliver technique for

distal vessel perforation

2. Contrast echo to ensure

pericardial bleeding has stopped

3. Know your coils!

Lessons

Wilson et al. CCI 2015;86:407–41

Wilson et al.

CCI 2015;86:407–41

Lesson

Perforation in the

post CABG patient

can be a lethal

complication – and

very hard to treat

1. Watch your wire!

2. Exchange polymer wires

3. Don’t ignore distal vessel perf

(tamponade can happen hours

later)

4. Prior CABG: perforation NOT

safe!

5. Block and deliver fat first

6. Know how to use coils

DISTAL WIRE PERFORATION: summary

Types of coronary perforation

Main Vessel

perforation

Distal Vessel

perforation

Collateral

perforation

Lesson

Epicardial collateral

perforation requires sealing

from both sides

CORONARY

1. Vessel closes

• Dissection

• Embolization

• Spasm

• Pseudolesion

2. Vessel Leaks

• Perforation

3. “Wrong place”

• Equipment loss

PCI complications: a classification

HEART

1. MI

2. Arrhythmia -

arrest

3. Tamponade

OTHER

1. Access

2. Thromboembolic

3. Contrast

• Nephropathy

• Allergies

4. Radiation

Mechanisms of stent loss

Brilakis, Garratt. Strategic Approach to coronary interventions 2005

RetrieveDo not

retrieve•Deploy

•Crush

“Attempts at removal may make things worse”

“Retrieval approaches require imagination, creativity, flexibility andexcellent visualization”

David R. Holmes, Jr, MD

Stent Loss

Stent retrieval: small balloon

technique

Brilakis, Garratt. Strategic Approach to coronary interventions 2005

Stent crushing

Brilakis, Garratt. Strategic Approach to coronary interventions 2005

Stent retrieval: loop snare

Brilakis, Garratt. Strategic Approach to coronary interventions 2005

Stent Loss 1

A

B

C

F

D E

Stent partially in left

main and partially

in aorta

Stent Loss 2

G H

I Successful

snaring

with

Ensnare

Stent

Loss 3

Conclusions

1. Complications happen!

• Learn how to detect and treat them

2. Perforation: inflate a balloon to stop

bleeding + pericardiocentesis if patient

hemodynamically unstable

3. Treat the cause

Large vessel perf: covered stent

Distal vessel perf: fat / coils

4. Remain calm – communicate with team