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CORONARY ARTERY

PERFORATION
Miftahul Afandi, MD
RSUD AM Parikesit Tenggarong Kutai Kartanegara,
Kalimantan Timur
Fellowship Interventional Cardiology,
RSUD Dr Soetomo Surabaya
DISCLOSURE STATEMENT OF FINANCIAL
INTEREST

I, (Miftahul Afandi) DO NOT HAVE A


FINANCIAL INTEREST/ARRANGEMENT OR
AFFILIATION WITH ONE OR MORE
ORGANIZATIONS THAT COULD BE
PERCEIVED AS A REAL OR APPARENT
CONFLICT OF INTEREST IN THE CONTEXT
OF THE SUBJECT OF THIS
PRESENTATION.
BACKGROUND
Complications of Percutaneous Coronary
Intervention

Ischemic Events
Stent Misadventures
Aortic Injury
Coronary Perforation
BACKGROUND
Coronary Artery Perforation (CAP) is a rare
The Incidence of CAP 0.8 % of PCI case
Potentially life-threatening complication of (PCI)

tamponade, and hemodynamic compromise


Risk Factors CAP : Clinical factors, Angiography
factors, and technique factors
Several Possible Mechanisms:
1. Perforation of the arterial wall by a sharp
object
2. Excessive ablation of parietal tissue by an
atherectomy device
3. Perforation caused by excessive stretching
of the vessel wall oversized balloon or
stent.
Etiology of Coronary Perforation

Wizcke Cf Cathdigest 2004


CLASSIFICATION

Ellis Type I : adanya extraluminal crater tanpa


ekstravasasi
Ellis Type II : adanya epicardial fat atau
myocardial blushing (1mm) tanpa contrast jet
ekstravasasi

Ellis Type III : adanya ekstravasasi dengan


perforasi yang jelas (1 mm) dengan contrast
streaming spilling
Ellis Type III with CS : adanya ekstravasasi
dengan perforasi
yang jelas (1 mm) dengan contrast streaming dan
cavity spilling
CLASSIFICATION

Type Extraluminal crater without


extravasation

Type II Pericardial or myocardial


blush without contrast jet
extravasation

Type Ill Extravasation through


frank (>1 mm) perforation
Cavity Perforation into an
anatomic cavity chamber,
spilling coronary sinus, etc
Major Registries for Coronary
Perforation

www.medscape.com
Algoritme penanganan diseksi dan
perforasi arteri koroner
CASE REPORT 1
Mr. EMR, 58 y.o
Chief complaint :
stable angina

Risk factors and medical history : hypertension;


smoking; post PCI
Physical exam : high blood pressure; signs of cardiomegaly
(apex displacement); others within normal limit

ECG : sinus rhythm, 75 bpm, normal axis


CXR : cardiomegaly CTR 58%

Lab : Hb 12.5, WBC 8330, Plt 213000,


BUN 11, Creat 1.1, Alb 4.0, AST 15,
ALT 15, Na 140, K 4.2, PPT/aPTT
normal
Angiography :
LAD : CTO in Proximal LAD
LCx : Stenosis 75% and 70 % at proximal & distal
RCA : Stented Vessel without significant restenosis

JOHN DOE, MD
SUBTITLE 32 PT ARIAL BOLD ITALICS
Angiography : CTO in pLAD; stenosis 75% and 70% at
proximal & distal LCx; RCA : stented vessel without any
significant restenosis

JOHN DOE, MD
SUBTITLE 32 PT ARIAL BOLD ITALICS

RCA
Percutaneous Coronary Intervention (PCI)

SUCCEED

Guiding catheter (GC) BL 3.5 7F to LMCA SUCCEED !

CTO in LAD :
Guidewire (GW) Fielder FC GW
Conquest Pro supported by microcatheter
Finecross
Guiding catheter (GC) BL
3.5 7F to LMCA
CTO in LAD :
Guidewire (GW) Fielder
FC GW Conquest Pro
supported by
microcatheter Finecross

D1 branch
perforation
(Ellis Type 3)
What should we do?

Bare Metal Stent


Prolonged
Balloon Micro coil
Inflation
Covered
Stent
Percutaneous Coronary Intervention (PCI)
Delivery negative
Pressure through
microcatheter

negative pressure via microcatheter act as vacuum


spasm effect intact vessel wall
Percutaneous Coronary Intervention (PCI)
Delivery negative RESULT : Sealed
Pressure through perforation, no residulal
microcatheter streaming
CASE REPORT 2
Mr. ISM, 54 y.o
Chief complaint : typical chest pain on exertion
Risk factors and medical history : hypertension;
dyslipidemia; prior myocardial infarction
Physical exam : high blood pressure; signs of
cardiomegaly (apex displacement); others within normal
limit
ECG : sinus rhythm, 84 bpm, normal axis, anteroseptal
wall old myocardial infarction, CXR : cardiomegaly CTR
60%
Lab : Hb 13.5, WBC 7330, Plt 223000, BUN 12, Creat 1.2,
Alb 4.5, AST 16, ALT 15, Na 141, K 4.4, PPT/aPTT normal
Angiography : CTO in pLAD; diffuse disease in LCx; stenosis 60% in
pRCA and 75% in dRCA. Syntax Score 38, Euro Score 0

JOHN DOE, MD
SUBTITLE 32 PT ARIAL BOLD ITALICS

LM, LAD, LCx


Angiography : CTO in pLAD; diffuse disease in LCx;
stenosis 60% in pRCA and 75% in dRCA. Syntax Score 38, Euro Score 0

JOHN DOE, MD
SUBTITLE 32 PT ARIAL BOLD ITALICS

LM, LAD, LCx


Angiography : CTO in pLAD; diffuse disease in
LCx; stenosis 60% in pRCA and 75% in dRCA.
Syntax Score 38, Euro Score 0

Patient refused to undergo CABG


and agreed on PCI
Percutaneous Coronary Intervention (PCI)

CTO in LAD :
Guidewire (GW) Asahi
Fielder XT 0.36 mm
GW Miracle 12
Guiding catheter (GC) SUCCEED !
Hearttrail II BL 3.5 7F to LMCA
Percutaneous Coronary Intervention (PCI)

JOHN DOE, MD
Guiding catheter
SUBTITLE 32(GC) Hearttrail
PT ARIAL II BL
BOLD ITALICS D1 branch
3.5 7F to LMCA coronary
perforation
CTO in LAD : (Ellis Type III with
Guidewire (GW) Asahi Fielder XT 0.36 cavity spilling)
mm GW Miracle 12
Percutaneous Coronary Intervention (PCI)

D1 branch coronary
perforation
(Ellis Type III with cavity spilling)

GW was withdrew

Rewiring

Prolonged Balloon
Inflation
(5-10 minutes)
Percutaneous Coronary Intervention (PCI)
Prolonged Balloon
Inflation
(5-10 minutes

Prolonged Balloon
Inflation
(5-10 minutes

stent placement
at the site of the
perforation
Percutaneous Coronary Intervention (PCI)

stent placement
at the site of the
perforation

the bare metal stent was not fully inflated


(underdeployed stent)
Percutaneous Coronary Intervention (PCI)
Deploying Bare Metal Stent at
the site of perforation

the stent was not fully inflated (underdeployed stent)


occlude and sealed the perforation; reaccess coronary
artery
Percutaneous Coronary Intervention (PCI)

not fully inflated sealed perforation


stent without residual
streaming

RESULT : sealed perforation without


residual streaming
SUMMARY
Coronary Artery Perforation (CAP) is a rare Potentially life-
threatening complication of (PCI)
Risk Factors CAP : Clinical factors, Angiography factors,
and technical factors
Therapeutic strategies include prolonged balloon inflation,
covered stents, reversal of anticoagulation, embolization of
the distal vessel and surgery
the choice depending on the site and severity of the
perforation, the patients hemodynamic status and the
equipment available in the catheterization laboratory.

Negative pressure through micro catheter and under


deployed stent alternative and potentially new applicable
technique
TERIMAKASIH

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