Thrombin Injection for Sealing Epicardial Collateral Perforation During Chronic Total Occlusion Percutaneous Coronary Interventions

ABSTRACT: Epicardial collateral perforation is a serious complication of retrograde chronic total occlusion percutaneous coronary intervention. We describe two cases of epicardial collateral perforation that were successfully sealed with local thrombin injection.

J INVASIVE CARDIOL: 2014;26(9):E124-E126

KEY WORDS: chronic total occlusion, perforation, thrombin, collaterals

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The retrograde approach has revolutionized percutaneous coronary intervention (PCI) of chronic total occlusions (CTO), by significantly increasing procedural success rates;^1-4 however, it also carries risk for complications, such as donor vessel and collateral vessel injury.^5,6 Epicardial collateral perforation is a potentially catastrophic complication of retrograde CTO-PCI, as it can result in rapid tamponade, especially in patients without prior coronary artery bypass graft surgery.^5,6 Large vessel perforations are commonly treated with covered stent implantation, whereas collateral vessel perforations are usually treated with coiling due to their small diameter.⁵ We report two cases of epicardial vessel perforation in which thrombin injection was used to achieve hemostasis.

Case Reports. Patient #1. A 54-year-old man with accelerating angina presented for right coronary artery (RCA) CTO-PCI (Figure 1A). After failure of crossing the lesion antegradely, a retrograde approach was attempted through an atrial collateral since the cannulation of two septal perforator arteries revealed no connection to the RCA. After successful retrograde crossing (Figure 1B) of the CTO through an atrial collateral and stent implantation, guidewire removal revealed atrial collateral perforation (Figures 1C and 1D), while the patient remained asymptomatic. Coiling of the perforation was not considered to be a good option due to the existence of multiple collateral connections. The atrial collateral was wired with two Sion guidewires through two Corsair microcatheters (Asahi Intecc) advanced in both retrograde and antegrade direction. Approximately 0.2-0.3 mL of thrombin (reconstituted to 1,000 units/mL) were injected through each Corsair catheter (Figure 1E). The injection was slow in order to avoid thrombin spillover into the epicardial coronary arteries. After thrombin was injected, the microcatheters were flushed with a small amount of saline (0.1-0.2 mL) and were removed quickly without re-introducing wires to minimize the risk of migration of thrombin remnants. Repeat angiography after 5 minutes revealed complete sealing of the perforation, while maintaining an excellent procedural result (Figure 1F).

Patient #2. A 64-year-old woman with prior coronary artery bypass graft surgery and multiple coronary interventions presented with lifestyle-limiting angina and was referred for RCA CTO-PCI (Figure 2A). After antegrade crossing failure, the retrograde approach was attempted through an apical collateral branch originating from the left anterior descending artery (Figure 2A, arrow). Upon partial withdrawal of the Corsair catheter that was used for crossing (Figure 2B), apical collateral perforation was detected (Figure 2C). The patient remained hemodynamically stable. A second Corsair catheter was advanced over an externalized Sion guidewire (Asahi Intecc) in the antegrade direction proximal to the site of perforation. After guidewire removal, 500 units of thrombin diluted in a small amount of contrast were injected (Figure 2D) simultaneously through both the antegrade and retrograde microcatheters, successfully sealing the perforation (Figure 2E). After thrombin injection, the Corsair catheters were gently flushed with saline to clear any remaining thrombin and were removed quickly without reinserting wires to minimize the risk for distal embolization of thrombin. The RCA was stented with four overlapping drug-eluting stents with an excellent final angiographic result (Figure 2F).

Discussion. Epicardial collateral perforation is a serious complication of retrograde CTO-PCI that can result in rapid tamponade requiring pericardiocentesis, especially in patients without prior coronary artery bypass graft surgery.^5,7 Unlike main vessel perforations, which are usually treated with covered stent implantation, collateral vessel perforation is usually treated with coiling.⁵ However, coil implantation requires insertion of a large microcatheter, such as the Renegade (Boston Scientific) or the Transit (Cordis Corporation), whereas thrombin injection can be performed through the Corsair. Another treatment option is application of negative suction through the microcatheter, which can result in collapse of the vessel wall and cessation of bleeding; however, the hemostasis obtained may be transient. Reversal of anticoagulation might result in self-sealing of the perforation, but could also result in catheter thrombus formation and distal embolization. Balloon inflation across the origin of the perforated collateral is not a good option because blood extravasation would continue through the other end of the collateral. Balloon inflation within the collateral vessel itself should be avoided in small collateral vessel as they may cause perforation.⁸ Covered stents are not a good option for treating collateral vessel perforation because two covered stents should be implanted, one at each end of the collateral vessel.

To the best of our knowledge, our report is the first to describe use of thrombin for sealing epicardial collateral perforation that occurred during retrograde CTO-PCI. Thrombin is supplied as sterile, freeze-dried power that is reconstituted using normal saline. The reconstituted solution usually has a concentration of 1,000 units/mL. Thrombin has been used in peripheral⁹ and native coronary artery^10-13 perforations at doses ranging from 200-330 IU for coronary perforations¹¹ and 400-2000 IU for peripheral pseudoaneurysms.¹⁴ In our cases, thrombin was mixed with a small amount of contrast to allow visualization of delivery within the perforated segment and was injected slowly to avoid spilling over into the main vessel. A small volume (0.2-0.3 mL) of thrombin was injected through each Corsair catheter. In both of our cases, successful CTO crossing had been achieved prior to detection of the perforation, enabling microcatheter insertion from both sides of the perforated segment, which protected against thrombin “spilling” into the main vessel, thus reducing the risk of main vessel thrombus formation. However, thrombin injection could have been successful in sealing the perforation even if injected from only one side of the perforation (if CTO recanalization had failed), as has been shown in peripheral arterial perforations.⁹

Extreme care should be taken when injecting thrombin to seal collateral vessel perforation, as thrombin could potentially cause a large myocardial infarction if it leaked into the main coronary vessel. Moreover, if the perforation occurs before recanalization of the CTO, occlusion of the collateral with thrombin might lead to ischemia or infarction of the myocardial territory supplied by the collateral, unless additional collaterals exist. Prompt recognition of epicardial collateral (or any type of) perforation can help expedite its management by reducing the likelihood of tamponade. Neither of our two patients developed a significant pericardial effusion and neither required pericardiocentesis.

In summary, thrombin injection can be utilized to seal epicardial collateral perforations during retrograde CTO PCI.

References

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From the ¹VA North Texas Healthcare System, Dallas, Texas, and University of Texas, Southwestern Medical Center, Dallas, Texas, and ²Columbia University, New York, New York.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Kotsia reports no disclosures. Dr Brilakis reports consulting honoraria/speaker fees from Sanofi, Janssen, St Jude Medical, Terumo, Asahi, Abbott Vascular, and Boston Scientific; research grant from Guerbet; spouse is an employee of Medtronic. Dr Karmpaliotis: speakers bureau Abbott Vascular, Medtronic, Boston Scientific, Bridgepoint Medical.

Manuscript submitted January 20, 2014, provisional acceptance given January 27, 2014, final version accepted January 29, 2014.

Address for correspondence: Emmanouil S. Brilakis, MD, PhD, Dallas VA Medical Center (111A), 4500 South Lancaster Road, Dallas, TX 75216. Email: esbrilakis@gmail.com