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Management of Guidewire-Induced Coronary Artery Perforations through Transradial Route-A Simple Approach
From the †Total Cardiovascular Solutions Private Limited, and Sheth V.S.General Hospital, Ahmedabad, India. The authors report no conflicts of interest regarding the content herein. Manuscript submitted June 19, 2009, provisional acceptance given July 20, 2009, final version accepted August 3, 2009. Address for correspondence: Tejas Patel, MD, FACC, FSCAI, Professor and Head, Department of Cardiology, Sheth V.S.General Hospital, Ahmedabad-380 006, India. E-mail: tejaspatel@tcvsgroup.org
_______________________________________________ ABSTRACT: We describe two cases of guidewire-induced Type-3 coronary artery perforations leading to pericardial tamponade treated successfully through a transradial approach using polyvinyl alcohol particles. This can be an effective, alternative, simplistic approach in the management of distal coronary artery perforations with hemodynamic compromise otherwise requiring surgical intervention.
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J INVASIVE CARDIOL 2009;21:E248–E251 Key words: coronary perforation, guidewire, polyvinyl alcohol, transradial approach, PTCA Although uncommon, coronary artery perforation is one of the most serious complications of percutaneous coronary intervention (PCI). The reported incidence varies from 0.1% to 3%.1–4 It has otherwise serious consequences resulting in an 8% incidence of death, an 18% incidence of myocardial infarction (MI) and a 13% need for emergency surgical management.5 We describe two cases of guidewire-induced coronary artery perforations successfully managed by transcatheter injection of polyvinyl alcohol (PVA) particles through a transradial approach using simple hardware. Case 1. A 50-year-old male patient with history of anterior wall myocardial infarction before 8 years, was admitted with exertional dyspnea and exertional angina. His coronary angiogram revealed a chronic total occlusion (CTO) of the proximal left anterior descending (LAD) artery with retrograde filling from the right coronary artery (RCA) collaterals (Figure 1A). The left main, RCA and left circumflex artery (LCX) were normal. Left ventricular (LV) angiography showed anterior-wall hypokinesia and severe LV dysfunction (LVEF of 15%). A stress thallium study confirmed partial viability of the LAD territory. The patient underwent intervention of the LAD CTO lesion. The left coronary artery was cannulated using a 6 Fr JL 3.5 Launcher (Medtronic, Inc., Minneapolis, Minnesota) guide catheter. Initial attempts to cross the CTO using 0.014 inch Miracle 3, Miracle 4.5, Miracle 6 and Miracle 9 PTCA wires (Asahi Intecc, Japan) failed. Finally, it was crossed using a 0.014 inch Miracle 12 PTCA wire. The lesion was dilated using a 1.5 x 12 mm and then a 2.5 x 12 mm Voyager PTCA catheter (Abbott Vascular, Santa Clara, California). After an adequate predilatation, it was stented using a 3.25 x 38 mm Zeta stent (Abbott). Post-stenting angiography revealed a clean stented segment, but multiple type-3 perforations (opening into the pericardial cavity) in the distal LAD and diagonal branches (Figure 1B). Subsequently, the patient developed chest discomfort and hypotension. Emergency table-side echocardiography revealed a large pericardial effusion with cardiac tamponade (Figure 2A). An injection of protamine was given to reverse the effects of heparin. Low-pressure balloon dilatations across the distal LAD and diagonal branches failed to seal the perforations. Emergency pericardiocentesis with autotransfusion was conducted to maintain hemodynamic stability. A covered stent was not considered in view of the small calibers of distal the LAD and diagonal branches. In this emergency situation, it a quick decision was needed in terms of hardware choice to successfully address the perforated distal segments via the transradial route. Hence, we used a 2.9 Fr Progreat microcatheter (Terumo Corp., Japan) as a carrier and a solution of PVA particles as an occluder. The distal tip of the microcatheter was almost wedged at the perforated segment to prevent significant reflux. We prepared a 3 ml mixture of 250–355 micron Contour Emboli (Target Therapeutics, Boston Scientific Corp., Natick, Massachusetts) with contrast agent to form a diluted, well-suspended solution and injected it into the distal LAD and then in the diagonal branch to occlude them. Final injection revealed successful occlusion of both sites and no leak in the pericardial cavity (Figure 1C). Repeat echocardiography 24 hours later revealed no pericardial effusion (Figure 2B). The patient remained hemodynamically stable during his hospital stay and was discharged after 3 days of observation. Case 2. A 45-year-old female presented with a history of chronic stable angina. Her thallium stress test revealed reversible ischemia in the inferior territory. Coronary angiography performed done via the right radial route revealed a normal left system and a CTO of the mid-RCA. Her LV angiogram showed mild hypokinesia of the inferior segments and a LVEF of 50%. The RCA was cannulated with a 6 Fr JR 3.5 Launcher (Medtronic) guide catheter. The RCA CTO was crossed using a 0.014 inch Cross-it 200 XT (Abbott) coronary guidewire, dilated using a 1.5 x 12 mm Voyager PTCA catheter (Abbott) and stented using a 3 x 18 mm Multilink Zeta Stent (Abbott). Post-stenting injection revealed a type-3 perforation of the distal posterior descending artery (PDA) opening in the pericardial cavity (Figure 3A). Emergency table-side echocardiography revealed a large pericardial effusion and cardiac tamponade. An injection of protamine was given to reverse the effects of heparin. Pericardiocentesis with autotransfusion was conducted. An attempt to seal the perforation with low-pressure balloon inflations failed. We decided to use the same strategy used in our previous case. We tracked a 2.9 Fr Progreat microcatheter (Terumo Corp, Japan) and wedged it at the perforated segment. We injected 250–355 micron Contour Emboli (Target Therapeutics, Boston Scientific Corp.) through it into the perforated segment (Figure 3B). A final injection revealed an occluded PDA beyond the mid-segment and no contrast leakage in the pericardial cavity (Figure 3C). Repeat echocardiography 24 hours later revealed no pericardial effusion. The patient was discharged 3 days later in hemodynamically stable condition. Discussion. Coronary artery perforations during PCI are rare but potentially life-threatening incidents that may require emergent surgery.8 The immediate sequelae to coronary perforation include death, cardiac tamponade, malignant arrhythmias and MI.5 The late sequelae include coronary aneurysm, pseudoaneurysm, or arteriovenous fistula formation.20 With conventional PCI, the incidence of perforation is estimated to be 0.1–0.2%, but may rise to 3% with the use of devices including directional atherectomy, rotational atherectomy, excimer-laser angioplasty, and extractional atherectomy.3–5,8 Hydrophilic PTCA wires such as the Choice PT (Boston Scientific) or the Whisper (Abbott Vascular) are more prone to cause distal coronary perforations.8,10 However, in current interventional practice, due to significant technological advances in CTO management, there has been a significant increase in the use of stiff-tipped CTO guidewires, which may lead to a higher incidence of guidewire-induced coronary perforations. The management of coronary artery perforations consists of either a nonsurgical or a surgical approach, or both. The treatment depends mainly on the type of perforation and also whether the patient develops cardiac tamponade or not.4 Type-1 or 2 perforations are usually managed conservatively since they have a more benign clinical course. However, type-3 perforations are associated with high in-hospital mortality (44%), with the majority of patients requiring emergency surgery (60%).4 The current nonsurgical management options for a perforated coronary artery include the use of prolonged balloon inflation and reversal of the heparin effect, which failed to seal the perforations in both cases presented here. The other option was the use of a PTFE-covered stent, which was not possible because of the distal location of the perforations and the very small caliber of the vessel at the perforation site. We thus decided to use PVA particles. In both cases, after preparing a 3 ml mixture of 250–355 micron Contour Emboli with contrast agent to form a diluted, well-suspended solution, we rapidly injected it into the culprit site after wedging the distal tip of a 2.9 Fr Progreat microcatheter (Terumo) to seal successfully seal it. The relatively heavy weight of the 250–355 micron PVA particles and their delivery in the antegrade direction of the bloodstream after appropriately wedging the distal tip of a 2.9 Fr Progreat microcatheter in the affected segment prevented any significant reflux in the small side branches as well as the major branches. Initially known for its use in household sponges and other domestic and industrial products, the biocompatibility of PVA has been established since its first medical application as a filling material following pneumonectomy.14 The PVA particle is also a commonly used embolic agent in patients with a variety of disorders including arteriovenous malformations, lower gastrointestinal bleeding, hepatic tumors, and bone metastases from renal-cell carcinoma.15–18 To our knowledge, there are only two published reports to date showing the use of PVA particles to seal coronary perforations.12,13 PVA particles are easily available in different sizes in most catheterization laboratories, making them an easier, convenient, and handy option to manage this type of serious iatrogenic complication. Moreover, because of their smaller particle size, PVA particles should be easier to optimally deliver to distal perforation sites using most microcatheter delivery systems. Depending on the disease process and the organ involved, the desired level of occlusion (i.e., proximal or distal) will determine the particle size selected for a given embolization procedure. The catheter must be small enough to allow selective catheterization of the vessel supplying the lesion, yet be large enough to deliver an embolic agent. The particles must fit through the catheter without causing catheter occlusion, yet not be so small that they pass through the capillaries. An over-the-wire balloon catheter was not considered as a carrier in both cases because its maximum internal diameter is 0.36 mm compared to 0.53 mm of the microcatheter. Since the PVA particle size is 250–355 microns, the chances of lumen occlusion with the over-the-wire balloon catheter are very high. Use of gel foam (absorbable gelatin — compressed sponge prepared from purified porcine skin-gelatin) and collagen with a 6 Fr Angio-Seal closure device (St. Jude Medical, Inc., St. Paul, Minnesota) have also been reported in nearly similar situations.10,11 However, it must be cut to the appropriate size, which may be more difficult to deliver with precision into very small distal branches of the coronary system using a microcatheter. The use of microcoil embolization to manage coronary perforations has also been reported,8 however, appropriate-sized microcoils must be available in catheterization laboratories for such an emergent situation. Recently, a microleak in the RCA was been successfully treated with intra-arterial glue injection. However, extra caution was required to prevent setting of the glue while in transit.21 The first patient had multiple perforations (distal LAD and diagonal) leading to cardiac tamponade. Both sites were sealed successfully using PVA particles without any untoward complications. The same technique was reproduced successfully for the second patient to seal the PDA perforation. Surgical management would have been high-risk in the first patient in view of his severe LV dysfunction. Also, it would have been inappropriate to subject the second patient to surgery just for the PDA territory. Moreover, both the cases were managed transradially using very simple and available hardware. To the best of our knowledge, these are the first reports of the successful management of guidewire-induced coronary artery perforations and cardiac tamponade via the transradial route.
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