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Diapositiva 1
Treatment of coronary perforations: material and techniques
Session 6: Safety AspectsDr. Luis Teruelrea de Malalties del CorHospital Universitari de Bellvitge - IDIBELLUniversitat de BarcelonaLHospitalet. Barcelona. Spain
www.bellvitgehospital.catBellvitge University Hospital LHospitalet de Llobregat. Barcelona. Spain. Three cath labs.Reference for 1.25 million people.1600 PCIs/year.200 IVUS/OCT/FFRStructural procedures: TAVR, ASD/PFO closures, mitral valvuloplasty, etc.Specific CTO program since 2007. 80-90 procedures/year. I am the main operator, performing approximately 60 CTO procedures/year, with a personal experience of 350 cases since 2007.
www.bellvitgehospital.catINDEXIncidenceClassificationMechanismsPredictive factorsMaterial and techniquesClinical outcomesH. U. Bellvitge experienceClinical cases
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1. Incidence
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n = 12729 coronary lesions in 7903 pat, 2004-2008Hendry, et al. EuroIntervention 2012;7:79-86Incidence (overall, non-CTO)
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Incidence (overall, non-CTO)Hendry, et al. EuroIntervention 2012;7:79-86n = 12729 coronary lesions in 7903 pat, 2004-2008
Perforation incidence: 0.56% (44/12,729)
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Incidence (CTO procedures)Patel et al, J Am Coll Cardiol Intv 2013;6:12836
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Incidence (CTO procedures)Patel et al, J Am Coll Cardiol Intv 2013;6:12836
2.90.3
www.bellvitgehospital.catIncidence (CTO procedures). Successful vs UnsuccessfulPatel et al, J Am Coll Cardiol Intv 2013;6:12836
www.bellvitgehospital.catIncidence (CTO procedures). Temporal trendsPatel et al, J Am Coll Cardiol Intv 2013;6:12836
www.bellvitgehospital.catIncidence (Retrograde CTO procedures)
El Sabbagh et al, Int J Cardiol 174 (2014):243248
www.bellvitgehospital.catEl Sabbagh et al, Int J Cardiol 174 (2014):243248Incidence (Retrograde CTO procedures)
n = 3482
www.bellvitgehospital.catSianos G. CTO and LM Summit. New York 2014 Incidence (CTO procedures)
www.bellvitgehospital.cat2. Classification
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Ellis ClassificationEllis et al. Circulation 1994;90:2725-2730.
IIIIII
www.bellvitgehospital.cat3. Mechanisms
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MechanismsGuide - Wire
Perforation(distal)
BalloonStentAtherectomy
Rupture(lateral)Disruption of the vessel wall through the intima, media and adventitia
www.bellvitgehospital.catMechanismsJavaid, Waksman et al. Am J Cardiol 2006; 98:911-914n = 38559 PCI, 1996-2005Perforation incidence: 0.19% (72/38559)
www.bellvitgehospital.catMechanismsHendry, et al. EuroIntervention 2012;7:79-86n = 12729 coronary lesions in 7903 pat, 2004-2008Perforation incidence: 0.56% (44/12,729)
www.bellvitgehospital.catMechanisms Ellis III PerforationAl-Lamee, Colombo et al. JACC Int 2011; 4:87-95n = 24465 PCI, 1993-2009Perforation incidence: 0.23% (56/24465)
www.bellvitgehospital.cat4. Predictive Factors
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Predictive FactorsHendry, et al. EuroIntervention 2012;7:79-86n = 12729 coronary lesions in 7903 pat, 2004-2008Perforation incidence: 0.56% (44/12,729)
www.bellvitgehospital.catPredictive Factors Ellis III PerforationAl-Lamee, Colombo et al. JACC Int 2011; 4:87-95n = 24465 PCI, 1993-2009Perforation incidence: 0.23% (56/24465)
www.bellvitgehospital.catPredictive Factors SummaryGuide-Wire distal-end stiffness
Hydrophilic coated wire (spontaneous sliding)
Older age
Female gender
Safenous vein
Severe calcification
High balloon stent-to-artery ratio. Postdilation
Atherectomy devices. Cutting balloon
CTO
High-pressure jet due to balloon rupture
www.bellvitgehospital.cat5. Material and techniques
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Stent Graft
Colombo et al. Cathet Cardiovasc Diagn 1996;38:172174.Romaguera et al. Catheter Cardiovasc Interv. 2011 Aug 1;78(2):246-53.Autologous Vein-Covered StentsMust be assembledJOSTENT Graftmaster (Abbott)PTFE sandwich 2 stentsOver and Under and Aneugraft (ITGI Medical)Pericardium covered stent
www.bellvitgehospital.catStent Graft
Direct-Stent (InSitu Technologies Inc.)Low profilePapyrus (Biotronik)Low profile
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Moses. CTO and LM Summit. New York 2013 Stent Graft
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Stent GraftPapyrus (Biotronik)Low profile
www.bellvitgehospital.catMesh Covered Stent
Romaguera et al. Catheter Cardiovasc Interv. 2012 Jul 1;80(1):75-8. MGuard (InspireMD)
www.bellvitgehospital.catSubcutaneous fatBlood clotCoilsParticles: Microshperes / GelfoamOnyxThrombinGluesEmbolization
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Moses. CTO and LM Summit. New York 2013 Coils
www.bellvitgehospital.catMoses. CTO and LM Summit. New York 2013 Coils
www.bellvitgehospital.catMoses. CTO and LM Summit. New York 2013 Coils
Platinum polyester fiber coils
Compatible with PTCA over the wire balloons or devices with 0.014 ID
Neuroradiology
Expensive
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Embolization particlesMoses. CTO and LM Summit. New York 2013
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Embolization particlesMoses. CTO and LM Summit. New York 2013
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Embolization particlesMoses. CTO and LM Summit. New York 2013
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Embolization particlesSianos. CTO and LM Summit. New York 2014
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OnyxMoses. CTO and LM Summit. New York 2013
www.bellvitgehospital.catThrombin: Radiotransparent. Can advance distally.
Glues (Gluebran): Can advance distally. Better with coils. RefrigeratorOther embolizations
www.bellvitgehospital.catManagement: Ellis I Perforation Stent Retrieval of guidewire Wait and seeUsually no futher complications
www.bellvitgehospital.catManagement: Ellis II Perforation Prolonged balloon inflation (at or proximal) Protamine (partially). Platelets ( IIb / IIIa) Pericardiocentesis ? Stent (StentGraft, M Guard) ? Coils ?High rate of only percutaneous management
www.bellvitgehospital.catManagement: Ellis III Perforation Prolonged balloon inflation (at or proximal). Protamine (partially). Platelets ( IIb / IIIa). Pericardiocentesis. Resuscitation measures. Embolization (distal): Negative pressure suction via microcatheterSubcutaneous fatBlood clotCoilsOnyxParticles: Microshperes (PVA) / GelfoamThrombinGlues Stent Graft (lateral). Emergent cardiac surgery.Dramatic. Life threatening
www.bellvitgehospital.catDual Catheter Technique for stent-graft implantation
Hendry, et al. EuroIntervention 2012;7:79-86Ben-Gal, Moses, et al. Catheter Cardiovasc Interv 75:708712 (2010)
www.bellvitgehospital.catManagement: Ellis IV Perforation Wait and see. Coils (distal). Stent Graft (lateral).Non emergent
www.bellvitgehospital.cat6. Clinical Outcomes
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Ellis et al. Circulation 1994;90:2725-2730.
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Clinical OutcomesHendry, et al. EuroIntervention 2012;7:79-86n = 12729 coronary lesions in 7903 pat, 2004-2008
Perforation incidence: 0.56% (44/12,729)
www.bellvitgehospital.catClinical OutcomesHendry, et al. EuroIntervention 2012;7:79-86n = 12729 coronary lesions in 7903 pat, 2004-2008Perforation incidence: 0.56% (44/12,729)
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Fasseas P et al Am Heart J 2004;147:1405
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Lance et al, JACC CI 2011;4:87
www.bellvitgehospital.catClinical OutcomesAl-Lamee, Colombo et al. JACC Int 2011; 4:87-95n = 24465 PCI, 1993-2009Perforation incidence: 0.23% (56/24465)
www.bellvitgehospital.catClinical OutcomesAl-Lamee, Colombo et al. JACC Int 2011; 4:87-95n = 24465 PCI, 1993-2009Perforation incidence: 0.23% (56/24465)
www.bellvitgehospital.catLong-Term Clinical OutcomesAl-Lamee, Colombo et al. JACC Int 2011; 4:87-95n = 24465 PCI, 1993-2009Perforation incidence: 0.23% (56/24465)
www.bellvitgehospital.catRetrograde Approach: Perforation in the retrograde channel
www.bellvitgehospital.catManagement Ellis III Perforation
Al-Lamee, Colombo et al. JACC Int 2011; 4:87-95
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Moses. CTO and LM Summit. New York 2013
www.bellvitgehospital.catAlways know where your wire is (or isnt) especially whether it is out of the vessel architecture or on a sidebranchAs a corollary :dont advance equipment unless it is where you hope it isAvoid oversizes balloons in calcified segments and subintimal spaces (IVUS can help here)Avoid atheroablation unless you are in the true lumenPerforations Avoidance
www.bellvitgehospital.catWatch Heart BordersOn Line EchoPan Over Whole Heart and Branches in Several Views with completion angioPerforations Detection
www.bellvitgehospital.cat7. H. U. Bellvitge Experience
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LEARNING CURVE
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RESULTADOS: End pointsTable 3. In-hospital angiographic and clinical outcomes. Procedural complications. Pre-CTO Programn=100 (CTO)CTO Programn= 350 (CTO)pIn-hospital outcomesAngiographic success, n (%)49 (49.0)325 (92.9)
