Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3764_Библиотеки_им_академика_М_И_Перельмана
.pdf
238 PART IV Wires Technique
CTO PCI was planned following a heart team evaluation. Pre-procedure right heart catheterization revealed
mildly elevated ventricular filling pressures and normal
CO and CI at 6.53 L/min and 3.54 L/min/m2, respectively. The PCI was planned without MCS placement
while continuously monitoring pulmonary arterial
pressures. The multivessel CTO PCI was performed
via bilateral radial artery access. Both LAD and LCX
CTOs were crossed using antegrade wiring techniques
with unchanged filling pressures CO and CI. Two
months later, successful CTO PCI of the RCA was
performed using an antegrade dissection reentry technique without the need of MCS because the patient has
patent LAD and LCX.
If possible, medical optimization of volume status and
hemodynamics optimization prior to CTO PCI can mitigate the need for MCS. Close monitoring by RHC and
the ability to place MCS emergently and safely are more
critical if the operator elects to defer MCS before the high
risk CTO PCI. Additionally, patients with severe lower
extremity peripheral arterial disease should have a plan
in the event of an urgent need for the placement of MCS.
While alternative access such as axillary or transcaval
access may be safely used for the placement of MCS,
these access routes may not be feasible or timely in an
emergency situation [24, 25].
Supported CTO PCI with IABP: A 75-year-old
male with atrial fibrillation, bioprosthetic mitral valve
replacement, and heparin-induced thrombocytopenia presented with heart failure and severe ischemic
cardiomyopathy secondary to multivessel coronary
artery disease. Coronary anatomy was notable for
severe proximal LAD disease affecting two large
diagonal branches. Also, there was a mid-LAD CTO
with the distal LAD supplied via left to right collaterals. A severe stenosis was also present in the mid left
circumflex coronary artery (LCX).
Echocardiogram was notable for severe LV
dysfunction and moderate mitral regurgitation. Cardiac magnetic resonance imaging demonstrated transmural enhancement of the mid to distal anterior
wall consistent with non-viable myocardium. Right
heart catheterization showed elevated biventricular
filling pressures associated with mild systemic arterial
hypotension. The cardiac output and index were low
2
at 3.41 L/min and 1.69 L/min/m
, respectively. The
patient was admitted for hemodynamic optimization
with diuresis over the next several days.
When the patient was brought to the cardiac catheterization, the LVEDP was measured and found
to be normal. Given improved hemodynamics and
minimal anticipated technical challenges, hemodynamic support with an IABP was selected for this
patient. The patient remained hemodynamically
stable throughout the successful multivessel PCI. This
case highlights the importance of hemodynamic optimization before high risk PCI in order to make the
procedure safer for the patient. It also illustrates best
practices for continuous hemodynamic monitoring
with a PA catheter during a procedure to monitor for
changes in hemodynamic status. Additionally, in the
event of deterioration, IABP access can allow a fast
exchange for a larger MCS device, avoiding the need
to obtain emergent large bore arterial access.
Supported CTO PCI with Impella CP: A 66-yearold male presented with decompensated heart
failure and syncope. He had several patient specific
risk factors for hemodynamic decompensated during high risk PCI including ischemic cardiomyopathy (LVEF 28%), multiple high risk coronary artery
lesions, diabetes mellitus, mildly reduced right ventricular function, and high filling pressures by RHC.
Coronary anatomy was notable for in-stent chronic
occlusions of the LAD and Ramus Intermedius as
well as de novo CTOs in the LCX and the RCA. The
previously placed stents in the mid to distal LAD
and the patient’s severely reduced LVEF precluded
CABG. Optimization before the planned PCI failed
to decrease the filling pressure adequately. RHC at
the time of high risk PCI showed severely elevated
biventricular filling pressures (LVEDP 38 mmHg) and
severely reduced CO and CI (3.47 L/min and 1.87 L/
min/m2, respectively). An Impella CP was placed
via left common femoral artery access, IVUS guided
CTO PCI of the LAD and ramus intermedius was performed with antegrade wire escalation. The Impella
was removed at the end of the procedure. The patient
returned for a scheduled RCA CTO PCI one month
later and was found to have similar hemodynamics
with elevated filling pressures and severely reduced
CO and CI of 2.78 L/min and 1.51 L/min/m2, respectively. Impella CP support was used again because of
the reduced cardiac reserve and the likely need for
retrograde collateral crossing (Figure 25.7). During
the procedure, loss of pulsatility was noted however
the patient maintained a mean arterial pressure above
70 mmHg throughout the procedure (Figure 25.8). At
the conclusion of the procedure, the pulmonary artery
catheter showed higher filling pressures and a further
reduction in CO/CI compared to the beginning of
the procedure. As a result, the Impella CP was not
removed, and the patient underwent hemodynamic
optimization with Impella support for several days.
The Impella CP was successfully removed, and the
patient was ultimately discharged. He returned for
staged LCX CTO PCI which was performed successfully without MCS given improved hemodynamics
following LAD and RCA revascularization.
Supported CTO PCI with TandemHeart: A 78-yearold female with paroxysmal atrial fibrillation presented
CHAPTER 25 Mechanical Support for CTO 239
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Figure 25.7 Impella supported RCA CTO PCI using retrograde crossing technique in a patient with severely reduced EF,
multivessel CAD, and elevated LVEDP. Arrow: Impella CP pump Arrowhead: Swan-Ganz pulmonary artery catheter
Asterix: R-CART technique for retrograde CTO crossing.
AQ 200 mmHg B
Figure 25.8 Loss of pulsatility in the aortic pressure waveform during supported CTO PCI with Impella 5.0. Mean aortic
pressure is maintained above 80mmHg. Arrow: Mean aortic pressure of 80mmHg.
with worsening heart failure and angina. The LVEF deteriorated from 40% to 22%, with a new moderate aortic
valve regurgitation by echocardiography. Coronary
anatomy was notable for severe stenosis in the left
circumflex artery and a CTO in the dominant and large
right coronary artery with epicardial collaterals from the
left circumflex artery to the RCA. The left main coronary
artery (LMCA) and the small left anterior descending
(LAD) had no significant stenosis. Although PCI of the
LCX could have been performed without MCS, abrupt
occlusion of the LCX or atherectomy procedures might
cause significant ischemia and stunning in two arterial
200
180
160
140
120
100
80
60
40
20
0
25 mm/s
240 PART IV Wires Technique
territories because the LCX provided all the major collaterals to the large and dominant RCA.
Moreover, the baseline right heart catheterization
showed low cardiac output despite normal filling
pressures. The calculated CO deficit was 1L/min and
was anticipated to worsen during planned retrograde
techniques used during RCA CTO PCI. The left atria
to arterial system (TandemHeart) pump was used
because of the large COD. Moderate aortic valvular
regurgitation is a contraindication for IABP and a
relative contraindication for trans aortic valve devices.
After successful revascularization of the LCX and the
RCA CTO, the RHC was used to guide the weaning
and decannulation of the TandemHeart.
Supported CTO PCI with LAVA ECMO: A 44-yearold male smoker presented with chest discomfort, and
dyspnea requiring mask positive pressure ventilation.
Echocardiography showed a 17% LVEF, RV dysfunction,
left and right ventricular thrombi, and severe mitral valve
regurgitation. A gadolinium cardiac magnetic renascence imaging study showed largely viable myocardium
except for a small transmural scar in the left ventricular
apex. There were CTOs in the second obtuse marginal,
proximal RCA, and ostial LAD as well as severe stenosis
in the large first obtuse marginal.
The distal coronary arteries were not suitable for
coronary artery bypass grafting (CABG). Following a
heart team evaluation, the decision was made to proceed with percutaneous revascularization. In this case,
severe biventricular dysfunction and multiple coronary
occlusions increased the risk of hemodynamic collapse
during CTO PCI. The presence of LV and RV thrombi
precluded the use of any device that need placement
in the ventricle. LAVA ECMO provided LV and RV
unloading and 4 – 6 L/min of flow in one device. The
baseline cardiac output and index were 4.12 L/min
2
and 2.09 L/min/m
, respectively. A transseptal atrial
puncture was performed utilizing intracardiac echocardiography guidance. The septostomy was then
dilated with an 8 × 60 mm peripheral balloon, and a
multifenestrated 24 French cannula was advanced into
the left atrium (Figure 25.9). The oxygenated blood was
returned by the pump to the arterial system via a 17
French cannula in the left common femoral artery.
Coronary revascularization was then begun with
IVUS guided PCI of the first obtuse marginal artery as the
intervention to OM1 was the least complex and carried
the lowest degree of risk. Following OM1 PCI, successful
LAD CTO PCI was performed with antegrade dissection and reentry. The mechanical circulatory device was
successfully weaned and removed with RHC guidance.
Subsequently, the patent LAD and first obtuse marginal
arteries allowed complete PCI revascularization of the
RCA CTO and second obtuse marginal without the
need for MCS during a staged procedure. Follow up in
three months demonstrated improvement in LVEF from
17% to 45% with significantly improved symptoms and
quality of life after complete revascularization.
Technical aspects of mechanical
circulatory support during CTO PCI
The IABP is the most commonly used device for high
risk PCI and supported CTO PCI. IABP is the simplest
MCS device to place as it only requires 7 or 8 French
arterial access. IABP can operate without anticoagulation
Figure 25.9 LAVA ECMO configuration with one fenestrated cannula. Arrows: LAVA ECMO cannula fenestrations
CHAPTER 25 Mechanical Support for CTO 241
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
if operated in one inflation per heartbeat (1:1) and does
not interfere with guide catheters engagement. However,
the IABP provides modest LV afterload reduction and
CO augmentation (approximately 0.5
L/min). While
the IABP does not directly improve coronary perfusion
distal to severe stenoses, it may improve coronary perfusion by modestly decreasing the left ventricular diastolic pressure. IABP is typically placed via the femoral
artery, though axillary artery access is also feasible. The
BCIS-1 trial demonstrated that IABP in elective highrisk PCI did not reduce major adverse cardiovascular or
cerebral events but did lead to decreased intraprocedural
hemodynamic compromise. A significant limitation in
the BCIS-1 trial was the relatively high cross over rate,
with 12% of the no IABP group crossing over to the
active therapy arm. Overall, the IABP is most suitable for
patients with a mild hemodynamic deficit or a relatively
low risk of ischemia leading to hemodynamic collapse
during the CTO PCI.
Microaxial flow pumps such as Impella are increasingly utilized for MCS in CTO PCI. The most commonly used device is the Impella CP. The microaxial
pump devices lie across the aortic valve and directly
unload the left ventricle. The Impella CP provides up
to 3.5–4.0 L/min flow. Unlike IABP, the microaxial
pump devices are not dependent on native LV ejection.
Important considerations to be aware of when choosing a microaxial flow pump during PCI includes interaction with the pump shaft and guide catheters making
engagement difficult during CTO PCI. Because of this,
we advocate seating the antegrade and retrograde guide
catheters before placing the microaxial pump device. It
might be better to avoid these devices if the CTO PCI
requires multiple engagements of SVGs or the RCA
during the procedure. The Impella CP is placed using a
14F sheath typically through the femoral artery, though
alternative access from the axillary or transcaval access
is also possible. A secondary guide catheter can also
be placed through the large bore access sheath of the
Impella CP using what is commonly referred to as a
“single access technique” [26]. In this technique, after
the Impella device is placed in the ventricle, the dam of
the 14 French sheath is punctured with a needle and a
6/7 slender sheath is advanced alongside the shaft of the
Impella device. It is also possible to place an 8F guide
catheter without a sheath. Guide manipulation however can be cumbersome and may lead to significant
interactions between the guide catheter and the Impella
during guide manipulation. The single access technique can also be utilized when a large sheath is used
for larger MCS device placement (Figure 25.10).
The large bore access required to place the Impella
device significantly increases the risk of bleeding complications. In the Protect II trial, 12.5% of patient had
BARC 3 or 5 bleeding. Though this rate has decreased
to <6% with contemporary vascular access practices,
bleeding complications with Impella remain higher
than IABP. New expandable microaxial pump devices
are currently under investigation. These expandable
devices allow placement of the microaxial device
through a smaller arterial access than 14 French. The
expandable devices have not been studied in CTO PCI.
The effectiveness of Impella was studied in the Protect
II trial. In the trial, the use of Impella 2.5 in elective
high-risk PCI did not reduce major adverse cardiovascular or cerebral events compared to IABP. However,
Figure 25.10 Single access technique.
242 PART IV Wires Technique
the per-protocol analysis showed improved outcomes
at 90 days, mainly driven by a decreased rate of repeat
revascularization.
TandemHeart is infrequently used in CTO PCI.
TandemHeart uses a 21 French venous cannula to drain
the oxygenated blood from the left atria to a centrifugal
pump that returns the blood to the arterial system via a
15 to 19 French transfemoral cannula. TandemHeart
provides 4 – 5 L/min flow. The use of TandemHeart
generally precludes the possibility of placing a guide
catheter in one of the femoral arteries. TandemHeart
does not interfere with coronary engagement by the
guide catheters during CTO PCI. Unlike microaxial
transaortic valve pumps, the TandemHeart can be used
in a patient with LV thrombus or mechanical aortic
valve. Given the need for a transseptal puncture, the use
of a TandemHeart for CTO PCI has been sporadically
described in case reports and case series [27]. The
TandemHeart device is associated with vascular access
and bleeding complications similar to those seen with
Impella devices. A lower extremity arterial reperfusion
sheath to perfuse the lower extremity is needed if the
TandemHeart device cannot be weaned and removed
at the end of the CTO PCI procedure.
Percutaneous VA-ECMO is also rarely used for supported CTO PCI. VA-ECMO can provide 4–6L/min of
cardiac output. The venous drainage cannula can be
placed from the femoral or the internal jugular vein
using a 21–29F cannula. The arterial outflow cannula
sizes range from 15–19 Fr. Use of VA-ECMO is typically
reported to have a higher rate of vascular access complications compared to Impella. This however has not been
well elucidated in the high-risk PCI cohort [28].
VA-ECMO typically increases LV afterload, and its
effect on left ventricular hemodynamics in high risk
PCI has not been well studied. A new left atrium and
venous to arterial (LAVA) ECMO configuration provides unloading of both sides of the heart. Like
TandemHeart, LAVA ECMO requires transseptal
puncture and dilation to place a multifenestrated cannula across the interatrial septum (Figure 25.9). The
multifenestrated cannula drains oxygenated and deoxygenated blood from the left and right atria respectively;
hence, it requires an oxygenator in the pump circuit.
The need to leave the MCS device for a prolonged
period following CTO PCI should always be considered during procedural planning. Prolonged large bore
arterial cannulation is associated with an increased
rate of complications and severe limb ischemia, leading
to a high risk of limb amputation. Surgical placement
with an arterial graft or transcaval access should be
considered when a large bore MCS device is expected
to remain in place for multiple days after the CTO PCI
procedure. On the other hand, distal limb reperfusion
can be achieved by channeling oxygenated blood from
the arterial side port of the MCS device to a 6–8 French
reperfusion sheath in the artery distal to the arterial
access of the MCS device (Figures 25.11, 25.12).
Bailout mechanical circulatory
support during CTO PCI
Hypotension, arrhythmia, or ischemic EKG changes
during CTO PCI warrant a careful assessment of the
patient hemodynamic status. It is essential to rule out
bleeding or coronary perforation before placing MCS
devices because, with the exception of IABP, all other
MCS devices require anticoagulation that will aggra-
Figure 25.11 Reperfusion sheath for prevention of leg ischemia. Arrow: Reperfusion sheath inserted antegrade in the
common femoral artery Arrowhead: Sheath-to-sheath connection for leg perfusion Asterix: Arterial ECMO cannula for
blood return.
CHAPTER 25 Mechanical Support for CTO 243
Extracorporeal Centrifugal Flow
Direct RV Bypass
Axial Flow
InDirect RV Bypass
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Figure 25.12 Reperfusion sheath for prevention of leg ischemia. Arrow: Reperfusion sheath inserted antegrade in the
common femoral artery Arrowhead: Sheath-to-sheath connection for leg perfusion Asterix: Arterial large bore access for
Impella 5.0.
vate any bleeding complication. RHC is essential to
determine the causes of the hemodynamic changes,
particularly if the immediate resuscitation measures do
not improve the patient’s hemodynamic status. Data
from right heart catheterization can confirm a diagnosis of cardiac tamponade, isolate hemodynamic
compromise to left, right, or biventricular failure, or
uncover hypovolemia due to occult bleeding. Pure RV
failure may result from occlusion of the RV marginal
branches during dissection and reentry or from an RV
wall hematoma. Cardiogenic shock from acute RV
failure often does not respond to inotropes or conventional MCS devices. Two different devices can achieve
right ventricular mechanical circulatory support. The
first device uses a centrifugal pump to drain the blood
from the right atria and pumps blood to the pulmonary
artery using a dual lumen cannula or two cannulas, one
in the RA and the other in the PA. The commercially
available device utilizing this mechanism of action is
the ProtekDuo. The second device displaces the blood
from the right atria to the PA using a coaxial pump
(Impella RP device) [29, 30] (Figure 25.13).
Emergency VA-ECMO placement is reasonable in
acute hemodynamic deterioration of unknown cause
as it supports the entire cardiopulmonary system
regardless of underlying cardiac performance.
VA-ECMO provides bridging while determining the
etiology of the hemodynamic deterioration.
MCS device complications
MCS devices are associated with vascular access and
ischemic limb complications as well as increased risk of
stroke and bleeding. Meticulous ultrasound and fluoroscopic guided access practices are critical during MCS
device placement to prevent complications. It is imperative to perform angiograms of the access site to confirm
the size of the vessels and the absence of arterial disease
before placement of large bore access. A baseline angiogram is also helpful to facilitate reperfusion sheath
placement to provide perfusion to the limb distal to
obstructive MCS arterial cannula or sheath [31].
When MCS is no longer necessary, safe removal is
key to avoid excess bleeding and vascular injury. MCS
can be removed via surgical or percutaneous techniques. When percutaneous techniques are employed,
several approaches can be employed. Hemostasis
in large bore venous access can be obtained with
Impella RP Ta ndem RVAD Pr otek Duo
Figure 25.13 Classifications of acute mechanical circulatory support devices for right ventricular failure [30]. Kapur et al.,
2017 / American Heart Association, Inc.
VA-ECMO
244 PART IV Wires Technique
Figure 25.14 Dry closure for hemostasis in large bore arterial access.
manual compression or figure of eight suture. Predeployed PerClose (Abbott, Abbott Park, IL) has
been used successfully to obtain venous hemostasis
after MCS device decannulation. Hemostasis in the
arterial access is obtained by placement of PerClose
before placement of the large arterial access or ad
hoc closure with the Manta device (Teleflex, Wayne,
PA). Dry access management is achieved by balloon
tamponade at or proximal to the arterial access. The
balloon should be semi-compliant and 1:1 size relative
to the artery [32, 33]. The balloon tamponade should
be achieved by inflating the balloon to the lowest
pressure that stops the bleeding, typically 2–4 atmospheres. Balloon tamponade can also be used in case
of closure device failure (Figure 25.14). If the balloon
tamponade for 20–30 minutes does not achieve hemostasis, anticoagulation reversal with Protamine and
further balloon tamponade can be attempted before
placement of self-expanding covered stents. Vascular
surgical closure should be considered to control the
bleeding and close the arteriotomy if initial measures
fail.
Conclusion
MCS is needed in approximately 5% of patients undergoing CTO PCI. The patient hemodynamic status,
comorbidities, and the planned procedures are essential
to determine the need for MCS and which device to use.
Right heart catheterization is very important to make an
informed decision about the hemodynamic status of the
patient and the adequacy of hemodynamic support
before, during, and after CTO PCI. MCS devices are
associated with increased risks of vascular complications
and stroke. This increased risk of complications should
be carefully weighed against the potential benefits of
MCS device use. Prospective studies of MCS during
CTO PCI are lacking and should be planned. Meanwhile,
observational data as well as expert consensus continues
to guide the use of MCS during CTO PCI.
References
1 Brilakis ES, Banerjee S, Karmpaliotis D et al. Procedural
outcomes of chronic total occlusion percutaneous coronary intervention: a report from the NCDR (National
Cardiovascular Data Registry). JACC Cardiovasc Interv
2015; 8(2): 245–253.
2 Mebazaa A, Combes A, van Diepen S et al. Management
of cardiogenic shock complicating myocardial infarction.
Intensive Care Med 2018; 44(6): 760–773.
3 Basir MB, Schreiber T, Dixon S et al. Feasibility of early
mechanical circulatory support in acute myocardial
infarction complicated by cardiogenic shock: the Detroit
cardiogenic shock initiative. Catheter Cardiovasc Interv
2018; 91(3): 454–461.
4 Basir MB, Schreiber TL, Grines CL et al. Effect of early
initiation of mechanical circulatory support on survival in
cardiogenic shock. Am J Cardiol 2017; 119(6): 845–851.
5 Sanborn TA, Sleeper LA, Bates ER et al. Impact of throm-
bolysis, intra-aortic balloon pump counterpulsation, and
their combination in cardiogenic shock complicating
acute myocardial infarction: a report from the SHOCK
trial registry. Should we emergently revascularize occluded
coronaries for cardiogenic shocK? J Am Coll Cardiol 2000;
36(3 Suppl A): 1123–1129.
CHAPTER 25 Mechanical Support for CTO 245
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
6 O’Neill WW, Kleiman NS, Moses J et al. A prospective,
randomized clinical trial of hemodynamic support with
Impella 2.5 versus intra-aortic balloon pump in patients
undergoing high-risk percutaneous coronary intervention: the PROTECT II study. Circulation 2012; 126(14):
1717–1727.
Perera D, Stables R, Thomas M et al. Elective intra-aortic
7
balloon counterpulsation during high-risk percutaneous
coronary intervention: a randomized controlled trial.
Jama 2010; 304(8): 867–874.
8
Danek BA, Basir MB, O’Neill WW et al. Mechanical
circulatory support in chronic total occlusion percutaneous coronary intervention: insights from a multicenter
U.S. registry. J Invasive Cardiol 2018; 30(3): 81–87.
9
Perera D, Stables R, Clayton T et al. Long-term mortality
data from the balloon pump-assisted coronary intervention
study (BCIS-1): a randomized, controlled trial of elective
balloon counterpulsation during high-risk percutaneous
coronary intervention. Circulation 2013; 127(2): 207–212.
10
Fincke R, Hochman JS, Lowe AM et al. Cardiac power is
the strongest hemodynamic correlate of mortality in cardiogenic shock: a report from the SHOCK trial registry.
J Am Coll Cardiol 2004; 44(2): 340–348.
Jain P, Thayer KL, Abraham J et al. Right ventricular
11
dysfunction is common and identifies patients at risk of
dying in cardiogenic shock. J Card Fail 2021; 27(10):
1061–1072.
12
Kong T, Dai X, Luan B, Zhang X, Hou A, Wang Y.
Predictors and prognosis of PCI-related myocardial
injury in chronic total occlusion. BMC Cardiovasc Disord
2022; 22(1): 454.
13
Simsek B, Kostantinis S, Karacsonyi J et al. Predicting
periprocedural complications in chronic total occlusion
percutaneous coronary intervention: the PROGRESSCTO complication scores. JACC Cardiovasc Interv 2022;
15(14): 1413–1422.
Ameloot K, Bastos MB, Daemen J et al. New-generation
14
mechanical circulatory support during high-risk PCI: a
cross-sectional analysis. EuroIntervention 2019; 15(5):
427–433.
15
Davies RE, Rier JD, McCabe JM. Patient and device
selection for hemodynamic support in high-risk percutaneous coronary intervention. Interv Cardiol Clin 2021;
10(1): 121–130.
16
Burkhoff D, Naidu SS. The science behind percutaneous
hemodynamic support: a review and comparison of support
strategies. Catheter Cardiovasc Interv 2012; 80(5): 816–829.
Cogswell R, John R, Shaffer A. Right ventricular failure
17
after left ventricular assist device. Cardiol Clin 2020;
38(2): 219–225.
18 Saxena A, Garan AR, Kapur NK et al. Value of hemody-
namic monitoring in patients with cardiogenic shock
undergoing mechanical circulatory support. Circulation
2020; 141(14): 1184–1197.
19 Rihal CS, Naidu SS, Givertz MM et al. 2015 SCAI/ACC/
HFSA/STS clinical expert consensus statement on the use of
percutaneous mechanical circulatory support devices in cardiovascular care (endorsed by the American Heart
Association, the Cardiological Society of India, and Sociedad
Latino Americana de Cardiologia Intervencion; Affirmation
of Value by the Canadian Association of Interventional
Cardiology-Association Canadienne de Cardiologie d’intervention). J Card Fail 2015; 21(6): 499–518.
Yoshitani H, Akasaka T, Kaji S et al. Effects of intra-aortic
20
balloon counterpulsation on coronary pressure in
patients with stenotic coronary arteries. Am Heart J 2007;
154(4): 725–731.
21
Alqarqaz M, Basir M, Alaswad K, O’Neill W. Effects of
impella on coronary perfusion in patients with critical
coronary artery stenosis. Circ Cardiovasc Interv 2018;
11(4): e005870.
22
Fiorelli F, Panoulas V. Impella as unloading strategy dur-
ing VA-ECMO: systematic review and meta-analysis. Rev
Cardiovasc Med 2021; 22(4): 1503–1511.
23 Alkhouli M, Osman M, Elsisy MFA, Kawsara A, Berzingi
CO. Mechanical circulatory support in patients with cardiogenic shock. Curr Treat Options Cardiovasc Med 2020;
22(2): 4.
McCabe JM, Kaki AA, Pinto DS et al. Percutaneous axil-
24
lary access for placement of microaxial ventricular support
devices: the Axillary Access Registry to Monitor Safety
(ARMS). Circ Cardiovasc Interv 2021; 14(1): e009657.
25
Afana M, Altawil M, Basir M et al. Transcaval access for
the emergency delivery of 5.0 liters per minute mechanical
circulatory support in cardiogenic shock. Catheter
Cardiovasc Interv 2021; 97(3): 555–564.
26 Wollmuth J, Korngold E, Croce K, Pinto DS. The single-
access for hi-risk PCI (SHiP) technique. Catheter
Cardiovasc Interv 2020; 96(1): 114–116.
27 Neupane S, Basir M, Alqarqaz M, O’Neill W, Alaswad K.
High-risk chronic total occlusion percutaneous coronary
interventions assisted with TandemHeart. J Invasive
Cardiol 2020; 32(3): 94–97.
Shaukat A, Hryniewicz-Czeneszew K, Sun B et al.
28
Outcomes of extracorporeal membrane oxygenation
support for complex high-risk elective percutaneous coronary interventions: a single-center experience and review
of the literature. J Invasive Cardiol 2018; 30(12): 456–460.
29
Akhmerov A, Ramzy D. Mechanical circulatory support
in right ventricular failure. Interv Cardiol Clin 2021;
10(2): 185–194.
30 Kapur NK, Esposito ML, Bader Y et al. Mechanical
circulatory support devices for acute right ventricular
failure. Circulation 2017; 136(3): 314–326.
Milano CA, Simeone AA. Mechanical circulatory
31
support: devices, outcomes and complications. Heart Fail
Rev 2013; 18(1): 35–53.
32 Buchanan GL, Chieffo A, Montorfano M et al. A “modi-
fied crossover technique” for vascular access management
in high-risk patients undergoing transfemoral transcatheter aortic valve implantation. Catheter Cardiovasc Interv
2013; 81(4): 579–583.
33 Zaman S, Gooley R, Cheng V, McCormick L, Meredith
IT. Impact of routine crossover balloon occlusion technique on access-related vascular complications following
transfemoral transcatheter aortic valve replacement.
Catheter Cardiovasc Interv 2016; 88(2): 276–284.
26
CHAPTER 26
Stent Grafts to Seal Coronary
Perforation
Jasleen Tiwana & Kathleen E. Kearney*
University of Washington Medical Center, Seattle, WA, USA
*Corresponding author
Introduction
During percutaneous coronary intervention (PCI),
coronary perforations occur in ~0.5 % of cases [1].
This risk is higher during chronic total occlusion
(CTO) PCI with perforations noted in 9 % of procedures. Data from the Outcomes, Patient Health Status,
and Efficiency in Chronic Total Occlusion Hybrid
Procedures (OPEN CTO) registry show that regardless
of techniques used, the majority of perforations occur
in the proximal, main vessel [2]In this context, it is
critical that CTO operators familiarize themselves
with the tools necessary for perforation management.
Nearly all clinical perforations are initially stabilized,
when feasible, with balloon tamponade across or
proximal to the perforation to occlude the inflow.
Fortunately, ischemic preconditioning in the CTO
territory usually allows for prolonged balloon tamponade and this may be definitive treatment in a
subset of less severe perforations. Following balloon
tamponade, repeat angiography to assess for contrast
extravasation guides the need for additional
management strategies. If it appears sealed this may
be monitored and hemostasis aided by heparin
reversal with protamine after all gear is removed from
the coronary [3].Proximal, large vessel perforations
more frequently require additional treatment with a
covered stent to achieve stability. When a small side
branch is the source of the perforation it may be prudent to stent across the side branch with a covered
stent to exclude the perforation. This is usually considered when coiling the small branch is disadvantageous due to a short segment of which to land the coils
and risk of propagation back to the main vessel, no
wire access to the side branch, or difficult microcatheter and subsequent coil delivery to the side branch
territory.
Types of covered stents
In the United States, two types of covered stents are
currently available: the Jostent GraftMaster (Abbott
Vascular, Santa Clara, CA) and the PK Papyrus
(Biotronik, Berlin, Germany) (Figure 26.1). Both stent
platforms were approved by the Food and Drug
Administration (FDA) through a Humanitarian
Device Exemption approval process, and thus require
Institutional Board Review (IRB) approval prior to
use. The GraftMaster stents were approved for use in
2001 for use in native coronary vessels or in saphenous venous grafts for the treatment of free perforations that are ≥ 2.75 mm in diameter. This device
consists of an expandable polytetrafluoroethylene
sandwiched between two identical stents made of surgical stainless steel. Contraindications for use include
patients who are unable to tolerate antiplatelet agents
or anticoagulation and lesions that prevent complete
inflation of an angioplasty balloon.
The PK Papyrus covered stent was approved by the FDA
in 2018. It is indicated for use in native arteries and bypass
grafts with a vessel diameter of 2.5 mm–5 mm. The device
is made of a cobalt chromium stent platform covered with
a polyurethane membrane. As with the GraftMaster
system, the device is contraindicated in patients who
cannot tolerate antiplatelet agents or anticoagulation and
lesions that cannot be reached or treated with the system.
Chronic Total Occlusions: A Guide to Recanalization, Third Edition. Edited by Ron Waksman and Shigeru Saito.
© 2024 John Wiley & Sons Ltd. Published 2024 by John Wiley & Sons Ltd.
246
CHAPTER 26 Stent Grafts to Seal Coronary Perforation 247
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Figure 26.1 Stent design of the Jostent GraftMaster and the PK Papyrus stents.
Covered stent: Sizing, deployment,
and optimization
Stent diameter should be chosen based on intravascular imaging already performed at the time of the
perforation with planned 1:1 sizing with the vessel
diameter. If imaging was not performed prior to the
complication the operator must rely on angiographic
estimation, keeping in mind the expansion capabilities
of both types of covered stents (Table 26.1). Longer
stent length should be chosen (if not resulting in side
branch compromise) given the difficulty identifying
the source of perforation in some cases, as well as
longitudinal shortening following stent expansion. In
the case of the GraftMaster stents, the covered length
of the stent can shorten up to 3.2
Papyrus stents may foreshorten up to 10
mm whereas the
% in length.
Delivery
Delivering covered stents requires knowledge of guide
catheter and guide extension compatibility with the
stents. Table 26.1 shows size compatibility of the two
types of stents with guide catheters and guide extensions. In general, the thinner stent struts, and single
stent design of the PK Papyrus allows for a lower pro-
file and easier deliverability, in part due to compatibility with 5Fr guide catheter systems [4].
The initial guide catheter used for balloon tamponade can be used to deliver the covered stent if they are
size compatible. In this setting, the tamponade balloon
is deflated and removed. The covered stent is then
delivered through the same system. In patients with
large perforations that may not tolerate the time
required for the exchange, a secondary guide can be
used to deliver the covered stent, often referred to as
“ping-pong guide” technique. In this case, the primary
guide is disengaged while the tamponade balloon
remains inflated to allow for coronary engagement
with the secondary guide. The tamponade balloon is
briefly deflated to allow for adjacent wire passage via
the 2nd guide. The tamponade balloon can again be
inflated to maintain hemostasis, and in more distal
locations this pinning of the secondary wire may
assist in delivering the covered stent to the site of perforation. Once the covered stent is just proximal to the
tamponade balloon it is deflated and withdrawn to
allow for deployment of the covered stent.
Stent dislodgment is a known possible complication of covered stent delivery. If the covered stent is
delivered through a tortuous or calcified proximal
vessel, the use of a guide extension is recommended to
Table 26.1
**
deployment pressure of 7 atm
Covered stent specifications.
GraftMaster GraftMaster Papyrus Papyrus
Guidewire compatibility (in) 0.014” 0.014” 0.014” 0.014”
Diameter (mm) 2.8, 3.5, 4 4.5, 4.8 2.5
Length (mm) 9, 12, 16, 19, 26 9, 12, 16, 19, 26 15, 20, 26 15, 20, 26
Maximum crossing profile (in) 0.064 0.068 0.056 0.070
Deployment pressure (nominal/rated burst)
(ATM)
Maximum stent expansion (mm) 5.5 5.5 3.5 for 2.5–3
Minimum guide catheter size (F) 6 7 5 6
Minimum guide extension size (F) 8 8 6 8
25 mm diameter PK Papyrus stents are not available in 26 mm length. 4 mm diameter PK Papyrus stents have a nominal
15/16 15/16 8/16 7/14
**
, 3, 3.5, 4**4.5, 5
4.65 for 3.5–4
5.63
Соседние файлы в папке Библиотека им академика М.И. Перельмана