“An iatrogenic Ellis type III coronary perforation, in which the “ping - pong guide catheter technique” with “mother and child” guide catheter extension technique were successfully

utilized to solve the problem„.

Anastasios D. Barmpas, MDCardiologistUniversity Cardiology DptMedical School, Democritus University of Thrace, Alexandroupolis, Greece

Disclosures

None to be declared

Case Presentation

A 58-year-old woman with a history of diabetes mellitus, dyslipidemia,and hypertension was referred for cardiac catheterization due tocrescendo angina pectoris. A myocardial scintigraphy study (SPECT)showed a large reversible anterior wall perfusion defect that indicatedLAD ischemia.

Case Presentation

Physical examination: unremarkable

Chest X-ray: normal

Electrocardiogram(ECG): anterior T wave changes

Transthoracic echo: demonstrated mild hypokinesia of the anterior wall with overall preservation of global left ventricular ejection fraction

Routine laboratory evaluation: unrevealing

Past medical history: disease-free

Medication: Olmesartan Medoxomil/HCT, Rosuvastatin, Gliclazide, vildagliptin

Case Presentation

• Vitals signs at admission time: HR 75 beats/min, BP 120/80 mmHg

• Pre procedure medications:

- 180 mg Ticagrelor p.o.

- 325 mg Aspirin p.o.

- 2500 U Heparin i.v.

Baseline Angiography

Left coronary angiogram showing the severe proximal-LAD lesion and the distal LAD lesion

Access: right radial artery Sheath: 6F GlideSheath Terumo with outer diameter 5F

Diagnostic catheter: 5F Tiger 4,0

Τreatment of proximal LAD Lesion

Postdilation with a 4 x 25 mm NC Balloon after Stent Deployment(18 Atm)

Predilation of proximal LAD with 3 x 25 mm compliant balloon (14 Atm)

Positioning of a 3,5 x 28 mm DE Stent(14 Atm)

Angiographic result in Prox. LAD Lesion

Treatment of distal LAD Lesion

Predilation of the distal LAD with a 2,25 x 20 mm compliant balloon at peripheral and proximal

lesion correspondingly (14 Atm)

Stent positioning and deployment of a 2,5 x 38 mm DE Stent at distal LAD (16 Atm)

Post-stenting angiographic result

• IVUS showed that the distal LAD stent was under-expanded and malapposed, as shown in the picture

IVUS showed that the distal LAD Stent was under-expanded and malapposed

• So, from IVUS we found that the Minimum Stent Area is under 5 mm 2 and we decided to proceed to postdilatationusing a NC Balloon 2,75 mm which we believe, according to the measurements we made with IVUS, was the rightchoice. Based on the multiple measurements of IVUS, the reference vessel diameter was 3 mm and knowing that theintracoronary ultrasound overestimates the diameter from 0.25 to 0.5 mm in comparison to QCA we chose a ΝCBalloon 2,75 mm.

• At IVUS image which is set out, you indicatively see that from 5 o’ clock to 8 o’clock position there is a large atheromatous load outside the stent. And yousee a plaque which is, indeed, of mixed echogenicity, that is to say it has acalcareous element which gives this acoustic shadow behind.

Postdilatation of distal LAD Stent

Postdilatation of distal LAD stent with a 2,75 x 26 mm Non- compliant balloon (18 Atm)

Iatrogenic Perforation Type III of distal LAD

According to our opinion, what happened is not due to a wrong choice of the balloon but unfortunately was something unpredictable since there was a calcium chunk, which possibly acted as splinter and caused the vessel perforation when

high pressure dilatation was performed.

Prolonged balloon Inflation

*ACT 240:No Reversal of Anticoagulation

Pericardiocentesis

500 ml blood

drained

Persistent extravasation in spite of prolonged balloon inflation for 20 Μinutes

Insertion of a second Guide Catheter forcovered stent delivery

The Ping-Pong Technique

Αdvantages of the „Ping-Pong Technique“➢ Second Guide Catheter minimizes duration of extravasation and subsequently the possibility of cardiac tamponade.

➢ The guide wire entrapment through the dilated balloon of the first catheter provides better support for covered stentdelivery specifically in spiral or calcified segments of the vessel or through already existent stents, like a “distal anchoringtechnique“.

ReferenceTreatment with the Double Guiding Catheter Technique for Type III Coronary PerforationRev bras Cardiol Invasiva 2013: 21:401-5 vol.21

Delivery of a covered stent with the Ping-Pong technique and a guide catheter extension

1 Catheter *

2 Catheter **

Guide Catheter Extension (7 Fr. Guideliner V2)

Covered Stent(PK Papyrus 2,5 mm x 20

mm (13 Atm)

Delivery of a covered stent with the Ping-Pong technique and a guide catheter extension

Key Message “Guideliner” improves back up support for covered stent delivery through previous implanted stent

Final angiographic result

• A contrast echocardiography was immediately performed for theexclusion of an active extravasation into the pericardium. A smallpericardial effusion was found without active extravasation.

• Follow-up of the patient at the Intermediate care station for 48 hours – the patient had no further complications.

• A myocardial scintigraphy study was carried out 6 months after theincident. There were no signs of ischemia.

Follow-up

Type I Extraluminal crater without extravasation

Type II Pericardial or myocardial blush without contrast jet extravasation

Type III Extravasation through frank (>1 mm) perforation

*Type III cavity spilling (CS) Perforation into an anatomic cavity, chamber, coronary sinus, etc.

*Sometimes referred to as Type IV

Ellis Classification of Coronary Perforation

Harries I et al,Eurointervention, 2014 Sep;10(5):646-7 Ellis et al,Circulation,1994;90;2725-2730

Ellis Classification of coronary Perforation

Anatomical classification of perforations

Anatomically, perforation is categorized as—

• Large Vessel Perforation

- usually more profound with greater likehood of significant sequelae

• Distal Wire Perforation

- There the aetiology is the guide wire (WIRE EXIT) and the clinical course isfrequently benign

• Collateral perforation

- occur in CTO PCI

- Epicardial collateral → Treatment includes both sides of the perforation(donor and recipient vessel)

Device Total Class II Class III

Guidewire 10 2 8

Stent 14 1 13

Cutting balloon 5 3 2

Post-dilatation 7 1 6

Predilatation 6 1 5

Late 2 0 2

Mechanism of Coronary Perforation

Hendry et al Eurointervention 2012 May 15;8(1);79-86

Several factors can be associated with Coronary Artery Perforation

Risk Factors:

Clinical Procedural

Complex lesions Atheroablative devices

Age Cutting balloons

Female gender Hydrophilic guidewire

Chronic total occlusion

Stiff guidewire

Presence of coronary calcification

Use of IVUS

Hypertension Oversized device

Acute coronary syndrome

Femoral approach

Heart failure

Harries I, Eurointervention 2014

Type 1 Perforation Management

Watchful waiting

Type 2 Perforation Management

➢Hydrophilic / CTO wires➢Distal perforation➢Embolisation:

• coils• thrombin• gelfoam / microshpheres•negative pressure suction via microcatheter•blood clot• subcutaneous fat

Type 3 Perforation Management

➢Prolonged balloon inflation (tolerated)➢Cardiac Tamponade - Pericardiocentesis➢Covered stent / 2nd guiding catheter➢Reverse anticoagulation (only if ACT is

greater than it should be)➢Surgery

Treatment Algorithmus of Grade III CoronaryPerforationsGrade 3 coronary perforation

Prolonged balloon inflation

Pericardiocentesis, cardiopulmonary resuscitation +/- IABP as necessary

Covered stent implantation

• Prolonged balloon inflation with IABP support• Coil embolization, if feasible• Surgical repair of perforation +/-

CABG

• Postdilatation of covered stent• Further covered stent implantation• Prolonged balloon inflation +/- IABP

support• Coil embolization, if feasible• Surgical repair of perforation +/- CABG

Heparin reversal +/- platelet

transfusion as necessary

No further treatment

Heparin or Gpllbllla

administered?

Evidence of continued contrast extravasation despite prolonged balloon inflation or intolerance to prolonged balloon inflation?

Evidence of continued contrast extravasation?

Hemodynamically unstable?

No further treatment

Yes

Intolerance to prolonged

balloon inflation

Yes

Distal coronary perforation or covered stent undeliverable

No

No

Yes

Yes

Al-Lamee R et all, JACC Cardiovasc Interv. 2011 Jan;4(1):87-95

Ismail Dogu Kilic, Coronary covered stents, Eurointervention, 20 November 2016

GRAFTMASTER BeGraft PK Papyrus Aneugraft Dx

Manufacturer Abbot Vascular Bentley Innomed Biotronik ITGI Medical

Graft material ePFTE ePTFE Electrospun polyurethane Processed equine pericardium

Stent material/designStainless steel

(316L)Sandwich design

Cobalt-chromium(L-605)

Single layer

CoCr (L-605) with amorphoussilicon carbide coating

Single layer

Stainless steel(316L)

Single layer

Guide catheter compatibility6 Fr (≤4.00 mm)

7 Fr (4.5 and 4.8 mm)5 Fr 5 Fr (stents <4.0mm)

6 Fr (stents ≥4.0mm)6 Fr

Crimped profile 1.63-1.73 mm 1.1-1.4 mm 1.18-1.55 mm 1.26-1.41 mm

Stent diameter (mm) 2.8-4.8 2.5-5.0 2.5-5.0 2.5-4.0

Stent length (mm) 16-26 8-24 15-26 13-27

Nominal implantation pressure15 atm 11 atm (2.5-4.0 mm)

10 atm (4.5-5.0 mm)8 atm (2.5-3.5 mm)7 atm (4.0-5.0 mm)

5 atm*

Information obtained from product catalogues. *Nominal pressure. Full stent opening requires ≤9 atm. CoCr: cobalt-chromium; ePTFE: expanded polytetrafluoroethylene

Covered Stents available in Europe

Material comparison table regarding Guide Catheter Extensions

DEVICE BRAND COMBATIBLEGUIDING CATHETER

INNER LUMEN

GuideLiner 5,5 Fr Vascular Solutions ≥ 0,066” 0,051”

GuideLiner 6 Fr Vascular Solutions 6Fr / ≥ 0,070” 0,056”

GuideLiner 7 Fr Vascular Solutions 7Fr / ≥ 0,078” 0,062”

Guidezilla Boston Scientific Corporation

6Fr / ≥ 0,070” 0,057”

Mother in Child Heartrail

Terumo 6Fr / ≥ 0,071” 0,059”

SummaryHow we can avoid this complication?

➢ Type III Ellis perforation is a rare but deadly complication, more frequent in calcified lesions, when high pressure dilatations areperformed and when an overestimation in vessel diameter is done.

➢ A proper preparation in calcified plaques to treat can prevent it.➢ Never underestimate calcified plaques.➢ If you are in a doubt about the diameter of the vessel, be cautious and use other techniques (e.g. IVUS or OCT) in addition to

angiography.➢ Sometimes, “The best is the enemy of the good” (Voltaire)

How we should manage this complication?

➢ Every cath lab should have a protocol to guide the treatment of this and other complications in order to combine a rapid response incardiopulmonary resuscitation maneuvers and pericardiocentesis with the appropriate percutaneous treatment.

➢ It is very important that each person working in the cath lab is trained in the proper use of stentgraft implantation with slow inflationand deflation.

➢ The Ping-Pong Technique is helpful to minimize hemorrhage through the coronary perforation during interventional repair.➢ Covered stent delivery through guide catheter extentions improves back up support through previous implanted stent➢ Stentgraft are more thrombogenic than other stents, and an appropriate antiplatelet regimen should be prescribed.