1. Complications of Percutaneous Coronary Intervention John S. Douglas Jr. MD Professor of Medicine Emory University School of Medicine SCAI International Fellows Course 2012 November 20, 2012 1:20PM

2. Disclosure Statement of Financial Interest Within the past 12 months, I or my spouse/partner have had a financial interest/arrangement or affiliation with the organization(s) listed below. Within the past 12 months, I or my spouse/partner have had a financial interest/arrangement or affiliation with the organization(s) listed below. Affiliation/Financial RelationshipCompany Grant/Research Support J&J,Medtronic,Boston Sci,Abbott,Medicines Consulting Fees/Honoraria None Major Stock Shareholder/Equity None Royalty Income None Ownership/Founder None Intellectual Property Rights None Other Financial Benefit None

3. Complications of PCI RecognitionPreventionManagement The Basics

4. Complications of Percutaneous Coronary Intervention Ischemic Events Stent Misadventures Aortic Injury Coronary Perforation

5. Basis of Major Ischemic Complications Vessel Closure Distal Embolization Myocardial Infarction Ischemic LV Dysfunction Emergency CABG Death

6. Emergent CABG in 41 Patients During 5875 PCI (0.7%) 1995-2000 Reasons For CABG Hopkins et al CCI 2001;53:99

7. Emergency Bypass Surgery 1979-2003 N= 23,087 Yang et al J Am Coll Cardiol 2005; 46: 2004

8. Coronary Dissection Remains a Significant Problem in the Stent Era ● Plaque fracture (due to balloon inflation or stent) ● Guide catheter or wire trauma ● Balloon rupture

9. Balloon Induced Dissection Treated Successfully with Stenting

10. Retrograde Left Main Dissection Safian et al Treatment: CABG, emergency stent if unstable

11. Common Mechanism of Left Main Injury from Left Amplatz Guide

12. Left Main Injury Following LAD Stent

13. Left Main Injury Treated with Stent Implantation

14. Iatrogenic Aortic Dissection Becoming a more common complication Secondary to guide catheter trauma, injection of wedged catheter or balloon rupture Class 1: Limited to coronary cusp Class 2: Limited to cusp and proximal ascending aorta Class 3: Extending to Aortic Arch

15. Class 1 Dissection Into the Right Coronary Cusp Successfully Treated with Stent Implantation Dunning et al Cathet. Cardiovasc. Intervent. 51:387, 2000.

16. Class 2 Dissection Extending Into the Aorta with RCA Occlusion Requiring CABG Dunning et al Cathet. Cardiovasc. Intervent. 51:387, 2000.

17. Class 2 Dissection Above the RCA Treated Successfully with RCA Stent

18. Class 3 Dissection Extending Into the Aortic Arch with Fatal Outcome Dunning et al Cathet. Cardiovasc. Intervent. 51:387, 2000.

19. Embolic Consequences of PCI No Reflow Myocardial Necrosis

20. Distal Embolism During Native (130) and SVG (64) PCI – Use of Filters 194 consecutive filter patients STEMI 38%, NSTEMI 32%, Angina 29% Major debris (particles >1mm dia.) was retrieved in 55% The only predictor of major debris was longer stent length (P<0.001) Conclusion: Filters should be considered in PCI of long lesions – El-Jack et al J Am Coll Cardiol 2006;47(Suppl A):A213A

21. Pre and Post PCI MRI and Troponin Demonstrate Myonecrosis Mostly Due To Distal Embolization 50 consecutive patients – all on Plavix + Reopro New Hyperenhancement – 28% (all had ↑Troponin) Stent length correlated with injury (P=0.04) Selvanayagam et al Circulation 2005;111:1027-1032 Correlation between troponin I and mass of hyperenhancement (amount of irreversible injury)

22. Patterns of Post-PCI Hyperenhancement Representing Focal Myo-necrosis Rarely Observed Adjacent To Stent Selvanayagam et al Circulation 2005;111:1027-1032

23. Patterns of Post-PCI Hyperenhancement Representing Focal Myo-necrosis Commonly Observed New Apical Defect Due To Embolization Selvanayagam et al Circulation 2005;111:1027-1032

24. SAFER Trial – Comparison of PercuSurge to Routine Stenting in SVG’s 801 Patients Randomized 30 Day MACE Reduced 42% P<0.001 Baim et al. Circulation 2002; 105: 1285. RoutinePercuSurge % 0 20 16.5% 9.6%

25. Management of No Reflow Avoid by using embolic protection ( and IIb / IIIa inhibitors ) when appropriate Support the patient (IABP if needed) Aspirate stagnant dye column Deliver microvascular dilators distally –Nipride or Calcium blocker – 50 to 100 mcg bolus –Adenosine – 10 to 30 mcg doses (t½ < 20sec)

26. Management of No Reflow Support the patient (IABP if needed) Aspirate stagnant dye column Deliver microvascular dilators distally –Nipride or Calcium blocker – 50 to 100 mcg bolus –Adenosine – 10 to 30 mcg doses (t½ < 20sec)

27. Coronary perforation during PCI in the IIb/IIIa Era J Am Coll Cardiol 1999; 33, 72A Cleveland Clinic 5,500 Patients; 31% Abciximab; 9 Deaths PerforationDeath 0 30 % 1.31.5 6% 24% No Abciximab Abciximab P=0.02

28. Coronary Perforation Classification Type 1Crater extending outside lumen only Type 2Pericardial or myocardial blush without > 1mm exit hole Type 3Contrast jet through > 1mm exit hole Ellis et al. Circulation 1992; 88: I-787

29. Type 2 Perforation Following Stent Implantation

30. Type 2 Perforation Following Prolonged Balloon Inflation

31. Causes of Coronary Perforation During PCI 1995-1999 at Christ Hospital 36 Perforations Guide Wire BalloonStentRotablaterDCALaser/TEC Dippel et al. Cathet Cardiovasc Intervent 2001; 52:279-286 Number of Patients 0 15 5 10 Odds Ratio Perf. 16 Type 3 Perf. 29

32. Risk associated with Type 3 Perforation Ellis et al. 1992Dippel et al. 2001 Tamponade63%43% Surgery75%50% QMI29% Death14%21%

33. Cardiac Tamponade Complicating PCI – An 8 year experience at William Beaumont Hospital Fejka et al. Circulation 2001; 104: II-417 % 36 Patients In-Lab 56 Out-of-Lab (mean 5 hours) SurgeryMIDeath 44 39 29 42 60 0

34. JoMed PTFE Covered Stent for PCI Perforations Lansky et al. JACC 2000; 35: 26A Multicenter Study of 35 Patients Pericardial effusions22% Tamponade14% Complete Sealing100% Q Wave MI0 Emergency Surgery0 Death0

35. Small “Stain” Noted on the Inferior Wall During RCA Stent Procedure Reopro Discontinued

36. Tamponade 3 hrs later: Balloon Occlusion Sealed Perforation Only After Distal Platelet Injection

37. PCI of Chronic Total Occlusion Difficult Wire Passage

38. Type 3 Perforation Following Inflation of 1.5mm Balloon

39. Type 3 Perforation Treated with Coil Embolization

40. Coronary Perforation - Diagnosis - ● Angiographic (blush, jet, coronary sinus compression, contrast in pericardium) ● No angiographic evidence in 10-20% ● ECHO (Not needed in 50% at Beaumont) ● Delayed tamponade common (wire induced & IIbIIIa)

41. Management of Coronary Perforation Hemodynamic Support ● Volume and inotropes ● Pericardiocentesis (pigtail) ● IABP (to resussitate) Seal Perforation ● Reverse heparin ● Balloon occlusion ● Platelets (abciximab) ● Embolization (coil, gel foam, thrombus) ● Covered stent (Jomed available) ● Surgery

42. Stent Maldeployment Imprecise placement Stent entrapment in uncrossable lesion Unexpandable lesion Sheared off by guide catheter Lost!

43. Stent Embolization Systemically – generally “safe” Intracoronary –Deploy (if on wire) –Crush (if off wire) –Retrieve with snare or wrapped in parallel guide wires or on small balloon

44. Mayo Clinic Experience 11,773 PCI’s ●Stent loss in 0.32% ● Successful retrieval 35/38 - balloon expansion and withdrawal 45% - snare 26% -twisted wires 5% -forceps 12% Brilakis et al CCI 2005;66:33

45. Conclusion ● Complications of PCI have decreased with routine use of intracoronary stents ● However, abrupt closure, perforation, atherothromboembolization and stent regret continue to challenge the interventionalist. ● Attention to prevention, recognition and treatment of these complications is essential

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