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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3764_Библиотеки_им_академика_М_И_Перельмана
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248 PART IV Wires Technique
help mitigate this risk. Additionally, the guide
extension may help occlude inflow to the perforation
when not practicing a ping-pong technique. Operators
should monitor for resistance when passing the
covered stent through the ramp of the guide extension
to ensure under fluoroscopic visualization that the
stent does not dislodge while traversing this transition.
Notably, only the PK Papyrus stents that are 4 mm in
diameter or less are compatible with a 6 Fr guide
extension. Therefore, if ping pong guide technique is
used, femoral access with an 8 Fr system would allow
for the most options for stent delivery. Lastly, if multiple stents are required, stenting from distal to
proximal is ideal to avoid interaction between the
covered stents that could lead to stent dislodgment.
Deployment and optimization
The nominal deployment and rated burst pressures
are indicated in Table 26.1. The GraftMaster stents
have a high nominal deployment pressure compared
with PK Papyrus stents. If the ping pong technique is
used to deliver a covered stent, ideally the primary
wire and tamponade balloon should be removed prior
to covered stent deployment to avoid gear entrapment. Following stent deployment, angiography
should be used to assess for adequate seal with post
dilation performed to optimize the hemostasis.
Outcomes
Given the specialized indication for covered stents,
large trials are not available to address short- and
long-term outcomes. The risk of stent thrombosis following implantation of a covered stent is higher compared to drug eluting stents but reports are variable
and likely impacted by additional clinical variables
including vessel outflow and anti-platelet use. Pooled
data for 725 patients show that in-stent thrombosis
occurs in approximately 4 % of patients with a PK
Papyrus stent versus ~9 % in patients who received
PTFE GraftMaster covered stents. In-stent restenosis
rates are similar for GraftMaster covered stents compared to PK Papyrus (4.4 % vs 3 %) with similarly high
rates of target lesion revascularization (11.6 % vs
7.4 %), but tamponade rates were also lower in the
Papyrus cohort (16 vs 29 %) and so ascertainment of
these competing outcomes may impact the reported
outcomes [5].Subacute and acute stent thrombosis
rates were reported as low as 1.1 % in the PK Papyrus
post-market registry, but another French cohort
reported in-hospital stent thrombosis in 5 % and 8 %
long-term, with target lesion failure due to ISR in
another 9 % [6].
Special consideration
Covered stents are often required in large proximal
vessel perforations, but they pose the risk of side branch
occlusion. This can result in significant ischemia when
considering covered stent deployment for perforations
in the left main coronary artery, ostial left anterior
descending (LAD), or ostial left circumflex (LCx).
Fenestration of the PK Papyrus stent to rescue a side
branch has been described [7] If side branch occlusion is
anticipated with rescue of the side branch desired, operators may employ the following technique to successfully rescue the branch. Prior to covered stent
deployment in the main branch, a workhorse wire is
inserted into the side branch to mark this vessel. A short
drug-eluting stent may be deployed in the proximal side
branch to serve as a subsequent target as well. A covered
stent is deployed in the main branch, intentionally jailing the side branch, a stiff coronary wire such as the
Astato XS 20 (ASAHI INTECC, Aichi, Japan) is used
fenestrate the covered stent, while using the jailed wire
and/or side branch stent as a reference. Wire de-escalation should be performed, and the jailed wire removed.
Following this, a drug eluting stent can extend coverage
back in Culotte technique or an additional covered stent
can be deployed in the side branch if required for hemostasis. If another covered stent is deployed, the same
technique can be used to fenestrate the side branch
covered stent. Post dilation, kissing balloon angioplasty
and proximal optimization technique should be
employed to ensure seal of the coronary perforation,
adequate stent expansion, and to avoid significant stent
malformation. This is a bailout technique given anticipating of increased rates of long-term stent failure but
has been employed as an important salvage technique in
high-risk scenarios. The GraftMaster stent does now
allow the same fenestration technique, and as such a
simultaneous kissing stent strategy has been used to salvage left main perforations as a temporizing maneuver.
Conclusion
Covered stents are a necessary tool to manage large
proximal vessel perforations or to exclude a small
bleeding side branch. Deliver issues with both types of
available covered stents warrant care during this
maneuver amidst a stressful scenario for the operator,
staff and patient. Device compatibility of the covered
stents with respect to sizing to the vessel, guide catheter
and guide extension is key to successful implantation.
Short- and long-term complications include increased
rates of in-stent thrombosis and in-stent restenosis/
target lesion revascularization as compared to modern
drug-eluting stents.
CHAPTER 26 Stent Grafts to Seal Coronary Perforation 249
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References
1 Ellis SG, Ajluni S, Arnold AZ et al. Increased coronary per-
foration in the new device era. Incidence, classification,
management, and outcome. Circulation 1994; 90(6): 2725–
2730. doi: 10.1161/01.CIR.90.6.2725.
2
Hirai T, Nicholson WJ, Sapontis J et al. A detailed analysis
of perforations during chronic total occlusion angioplasty.
JACC Cardiovasc Interv 2019; 12(19): 1902–1912.
Doll JA, Hira RS, Kearney KE et al. Management of percu-
3
taneous coronary intervention complications. Circ
Cardiovasc Interv 2020 Jun. doi: 10.1161/CIRCINTE
RVENTIONS.120.008962.
4
Al-Mukhaini M, Panduranga P, Sulaiman K, Riyami AA,
Deeb M, Riyami MB. Coronary perforation and covered
stents: an update and review. Heart Views. 2011; 12(2):
63–70. doi: 10.4103/1995-705X.86017.
Nagaraja V, Schwarz K, Moss S, Kwok CS, Gunning M.
5
Outcomes of patients who undergo percutaneous coronary intervention with covered stents for coronary perforation: a systematic review and pooled analysis of data.
Catheter Cardiovasc Interv 2019; 29: 28306. doi: 10.1002/
ccd.28646.
6
HernándezEnríquez M, Belle L, Madiot H, Pansieri
M, Souteyrand G, Poli F et al. Use and outcomes of
the PK Papyrus covered stent in France: SOS PK
Papyrus Registry. Catheter Cardiovasc Interv 2021; 98:
874–881.
7
Werner GS, Ahmed WH. Fenestration of a Papyrus PK
covered stent to recover the occluded left main bifurcation after sealing a left main perforation during a CTO
procedure. Cardiovasc Revasc Med 2017; 18(6): 41–44.
doi: 10.1016/j.carrev.2017.03.006.
27
CHAPTER 27
Complications During Retrograde
Approach for CTO
Yutaka Tanaka* & Shigeru Saito
Shonan Kamakura General Hospital, Kamakura City, Japan
*Corresponding author
Introduction
The retrograde approach for chronic total occlusion
(CTO) carries a risk of critical complications.
Complications during retrograde PCI for CTO can be
either general or specific to the retrograde approach.
Operators may encounter unexpected complications.
We should hone our senses and be ready for any unusual
events that may occur during the retrograde approach.
Understanding possible complications of CTO-PCI
using a retrograde approach can facilitate prevention,
early recognition, and prompt treatment.
General complications and
retrograde approach
•
Air embolism.
•
Thrombus formation.
Insertion of a variety of devices into coronary arteries
during long-lasting CTO PCI may predispose patients
to thrombus formation. Unfractionated heparin is the
gold standard anticoagulant for CTO PCI, ACTs
should be kept at >300 seconds and checks should be
conducted every 30–60 minutes depending on much
the recent measurement exceeded the target ACT.
•
Coronary dissection.
Antegrade contrast injections should be avoided
after coronary dissection due to the risk of hydraulic
dissection.
•
Tamponade due to wire perforation or coronary
rupture.
Any complications that can be observed during standard PCI can occur during a retrograde approach. In
particular, hypotension is critical and often observed
during PCI for CTOs. It is important to quickly determine the causes of blood pressure reduction, which
may include:
•
Contrast-induced anaphylaxis.
•
Bleeding from access site or route to the coronary.
The retrograde approach usually requires double
arterial access, which means that the incidence of
access site complications is doubled. PCI operators
should familiarize themselves with both the transfemoral and transradial approach, especially in
patients for whom double access from the femoral
arteries may trigger complications.
•
Vasovagal reflex.
•
Guiding wedging.
•
Guiding-induced aortic regurgitation.
•
Guiding-induced coronary dissection.
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.
250
Complications specific to the
retrograde approach
A retrograde approach is associated with increased complications, some of which are unique to this approach.
These complications can be categorized as donor artery
ischemia, channel injury, and device-related problems as
follows:
1 Injury of the donor artery
2 Septal artery hematoma/aneurysm
3 Epicardial collateral channel perforation
4 Profound ischemia due to the collateral source
occlusion
5 Guidewire entrapment within septal channel
1 Injury of the donor artery
As strong backup support by the guiding catheter is
necessary to pass the microcatheters through small
and tortuous collateral channels, dissection of the
major collateral feeding artery may occur. If dissection
CHAPTER 27 Complications During Retrograde Approach for CTO 251
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of the donor artery is suspected, it should be adequately handled using quick stenting (Figure 27.1).
Septal artery hematoma/aneurysm
2
An attempt to cross guidewires through tortuous
septal arteries may result in perforation and
subsequent septal hematoma. In a previous report on
this type of complication, the patient developed myocardial infarction [1].
We also encountered a case of a septal artery aneurysm that developed during an uneventful retrograde
approach through the septal artery using a Corsair
microcatheter. The patient rapidly developed cardiac
tamponade and shock. The patient recovered completely with hemostasis using metal coil embolization
of the septal artery from both the RCA and LAD ends,
and pericardiocentesis [2] (Case III in Chapter 41).
3
Epicardial collateral channel perforation
Epicardial perforation is a quite dangerous complication and can rapidly lead to pericardial tamponade.
The only treatment is embolization of the artery and
quick reversal of anticoagulation. Autologous fat
tissue can be used as embolizing material. However,
the use of a metal coil is recommended for embolization, because it is more reliable.
In some cases, a PCI operator might not notice
minor bleeding from the epicardial collateral channel
because a wedged microcatheter has stopped minor
bleeds during the procedure. Undetermined temporal
hypotension seen throughout the procedure could
have been a sign of channel perforation even without
significant epicardial effusion. Figure 27.2 shows a
case with late cardiac tamponade occurred a few hours
later.
Figure 27.1 Dissection of donor artery. (a) RCA feeds collateral to LAD through septal arteries. (b) Dissection of proximal
RCA created by a guiding catheter. (c) Stent was placed and procedure was continued. (d) Successful completion of
procedure.
252 PART IV Wires Technique
Figure 27.2 Late cardiac tamponade due to epicardial channel bleeding. (a) Occluded distal RCA and epicardial collateral
channel from LCX. (b, c) Retrograde Suoh03 wire assisted with FineCross reached the segment distal to the CTO through
the channel, allowing the antegrade wire to successfully cross the CTO. (d) Distal RCA was successfully recanalized with
3-stent implantation. (e) A couple of hours later, cardiogenic shock due to pericardial effusion occurred. (f, g) Vital signs
recovered following pericardiocentesis. Tiny perforations were suspected but had already stopped.
If a perforation is created at the junction between the septal and epicardial arteries, arterial
bleeding can invade the subepicardial space but
not the subpericardial space, resulting in subepicardial tamponade. This type of tamponade may be
localized and difficult to remove using percutaneous pericardiocentesis [3]. We successfully
treated this patient with surgical small-incision
pericardiocentesis (Case IV in Chapter 41).
4 Profound ischemia due to collateral source
occlusion
If the major epicardial collateral route is used, the
introduction of a wire and/or microcatheter into
the channels may occlude the blood flow supplying
the area distal to the CTO lesion and provoke profound ischemia. In this situation, the operator must
decide whether to stop or continue the procedure
(Figure 27.3).
CHAPTER 27 Complications During Retrograde Approach for CTO 253
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Figure 27.3 Reduction in blood supply through collateral feeding artery. (a) RCA feeds collateral to LAD through apical
connection. (b) Total occlusion of LAD. (c) Apical connection showed false spasm after crossing a wire, and severe
ischemia was induced. (d) Successful completion of procedure.
5 Guidewire entrapment within septal branch
The maneuver of crossing a guidewire through tortuous
septal branches causes stress to the wires. As a result, the
wires may be entrapped in the septal branches, resulting
in fractures. It is a very rare but important complication
[4]. If wire entrapments are felt, a microcatheter should
access to echocardiography, pericardiocentesis kits,
various types of embolic coils, and intra-aortic balloon
pumps. In general, serious complications during the
retrograde approach are not frequently observed, and
these complications can be managed adequately with
close observation and handling [5, 6].
be advanced as close as possible to the distal tip of the
wire, and then both the microcatheter and guidewire
should be pulled together for retrieval. This procedure
may prevent complete fracture of the guidewire.
Conclusion
During the retrograde approach for CTO lesions, we
should be very sensitive to any changes in patient conditions. Operators should always be ready for quick
References
1 Lin TH, Wu DK, Su HM et al. Septum hematoma: a com-
plication of retrograde wiring in chronic total occlusion.
Int J Cardiol 2006; 113: e64–e66.
2 Hashidomi H, Saito S. Dilation of the septal collateral
artery and subsequent cardiac tamponade during retrograde percutaneous coronary intervention using a microcatheter for chronic total occlusion. J Interv Cardiol 2011;
24: 73–76.
254 PART IV Wires Technique
3 Matsumi J, Adachi K, Saito S. A unique complication of
the retrograde approach in angioplasty for chronic total
occlusion of the coronary artery. Catheter Cardiovasc
Interv 2008; 72: 371–378.
4 Sianos G, Papafaklis MI. Septal wire entrapment during
recanalisation of a chronic total occlusion with the retrograde approach. Hellenic J Cardiol 2011; 52: 79–83.
5 Saito S. Different strategies of retrograde approach in
coronary angioplasty for chronic total occlusion. Catheter
Cardiovasc Interv 2008; 71: 8–19.
6 Okamura A, Yamane M, Muto M et al. Complications
during retrograde approach for chronic coronary total
occlusion: sub-analysis of Japanese multicenter registry.
Catheter Cardiovasc Interv 2016; 88: 7–14.
V
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PART V
Interesting Cases
28
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CHAPTER 28
Interesting Cases I–V
Yutaka Tanaka* & Shigeru Saito
Shonan Kamakura General Hospital, Kamakura City, Japan
*Corresponding author
Case I (Figure 28.1)
Interesting points
Blowout type coronary rupture at a severely calcified
chronic total occlusion (CTO) lesion.
History and PCI procedure
A 76-year-old man with hypertension and insulindependent diabetes presented with a feeling of tightness on effort. Coronary angiography revealed CTO
with severe calcification of the RCA. We performed
PCI for the RCA via bi-femoral artery access. An 8-Fr
AL1.0 and 8-Fr AL1.0SH were inserted via both
femoral arteries. From the antegrade guiding catheter,
we were unable to pass the lesion due to heavy calcification in the angulated portion using either a
Conquest Pro (Asahi Intecc) or a Miracle (Asahi
Intecc) assisted by a Corsair Pro, despite using the
side-branch anchoring technique. From the retrograde guiding catheter, an SUOH03, assisted by a
ZIZAI (Terumo), passed through the atrial circumflex
channel. A Gladius EX reached the distal end of the
CTO in the RCA. Finally, using the reverse controlled
antegrade and retrograde tracking (CART) technique
and a Gaia Next 2, we were able to cross the CTO retrogradely to the antegrade guiding catheter. After
RG3 externalization, balloon dilatation of the lesion
was performed, followed by an IVUS examination.
Upon implantation of a 3.0 mm × 38 mm stent at the
CTO site, coronary rupture (Type III of the Ellis
Criteria) occurred. After completion of rapid stent
balloon tamponade, cardiocentesis was performed
and a temporary pacing lead was inserted. A
Graftmaster (3.5 mm × 19 mm, Abbott Vascular) was
implanted. The coronary rupture was successfully
treated. The patient was discharged without sequelae.
Coronary artery rupture can occur if a wire passes
close to the adventitia in an area of calcification. In
addition to the echocardiogram and preparation of
the pericardiocentesis kit, implantation of a covered
stent for the lesion in this case may have been a better
treatment choice. Clinicians should also be mindful of
placing a covered stent edge in a position to avoid the
area of calcification and enable complete sealing.
Case II (Figure 28.2)
Interesting points
Retrograde approach for a CTO lesion in the LCX
through the ipsilateral collateral channel.
History and PCI procedures
A 71-year-old man presented with chest oppression
on exertion. Coronary angiography revealed CTO in
the LCX. The distal LCX was supplied via the ipsilateral septal collateral vessel from the LAD. Antegrade
PCI of the LCX-CTO was performed using a 90 cmlong 7-Fr EBU 3.75 via the right radial artery.
However, because of the significant heartbeat
movement, wire control was extremely poor.
Therefore, we switched to the retrograde approach
using the same guiding catheter. After selection of the
septal artery with a SION (Asahi Intecc), an SUOH 03
(Asahi Intecc) with a ZIZAI microcatheter was
advanced into the distal LCX via the septal collateral
route. The direct crossing of the Gaia Next 2 failed
and the wire advanced through the subintimal space
in the CTO. Extended reverse CART was performed
with a combination of an antegrade 3.0
and a retrograde Gaia Next 2 wire. A retrograde
ZIZAI reached the proximal LCX over the CTO, and
the Gaia Next 2 was exchanged for a 300 cm RG3 wire
(Asahi Intecc). Externalization was performed using a
snare catheter. After small balloon dilatation, IVUS
examination, and larger balloon dilatation, the stent
was successfully implanted (Figure 28.4). This case
mm balloon
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.
257
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