Coronary perforation and

management
Friday, February 16, 2018
11.30 – 11.38 am

Emmanouil S. Brilakis, MD, PhD

Minneapolis Heart Institute
 Disclosures
Consulting/speaker honoraria: Abbott
Vascular, ACIST, Amgen, Asahi, CSI,
Elsevier, GE Healthcare, Medicure,
Medtronic, Nitiloop
Grants: Boston Scientific, Osprey
 PCI complications: a classification
CORONARY HEART OTHER
1. Vessel closes 1. MI 1. Access
• Dissection 2. Arrhythmia - 2. Thromboembolic
• Embolization arrest 3. Contrast
• Spasm 3. Tamponade • Nephropathy
• Pseudolesion 4. Shock • Allergies
4. Radiation
2. Vessel Leaks
• Perforation

3. “Wrong place”
• Equipment loss
 Survey of 1,149 cardiologists on CTO PCI

Patel S, Menon RV, Burke MN, Jaffer FA, Yeh RW, Vo M, Karmpaliotis D, Azzalini L, Carlino M, Mashayekhi K, Galassi A, Rinfret S, Ellis S, Patel M,
Rangan BV, Karatasakis A, Danek BA, Karacsonyi J, Resendes E, Banerjee S, Brilakis ES. J Invasive Cardiol 2018;30:43-50
PROspective Global REgiStry for the Study of CTO
interventions
www.progresscto.org

Danek et al. Am J Cardiol 2017;120:1285-1292

 Types of coronary perforation
Main Vessel Distal Wire Collateral
perforation perforation perforation

Dr. Minh Vo Drs. Sanjog Kalra + Raja Hatem

LAD CTO
 Predilation
– balloon
rupture

next step?

TIP: Balloon
rupture can cause
perforation
TIP: When a balloon ruptures do
an angiogram immediately!
}
“Universal” Algorithm for
Coronary Perforations

} Type-specific
Treatment
 Stop
bleeding
TIP: The first step in any
perforation is to inflate a
balloon proximally to stop
pericardial bleeding
 Graftmaster Rx PK Papyrus

HDE - IRB approval needed

2.8 - 4.0 mm stents: 6 French guide
4.5 and 4.8 mm stents: 7 French guide
Brilakis ES. Manual of coronary CTO interventions. 2nd edition. Elsevier 2017
Sealing a large vessel perforation
One or two
guide
catheters?
Ping-pong
 Unable to
deliver
2.80x19 mm
Graftmaster

TIP
Delivery of covered stents
can be very challenging
 Covered
stent
through
Guideliner

TIP
Graftmaster stents can fit
within an 8 Fr Guideliner
Perforation
sealed
 ACT=227

TIP
Perforation can be further
complicated by thrombosis
DON’T REVERSE HEPARIN UNTIL
AFTER EQUIPMENT REMOVED
FROM CORONARY ARTERY
Final result
TTE at the end

TIP
Early balloon inflation can
prevent tamponade
Case 2: Baseline
Angiography

RCA CTO
Wire externalization

Retrograde Corsair
Retrograde
crossing
After stenting
Balloon rupture during postdilation

Unable to deliver covered stent

After hours of More balloon
ballooning inflations...
 3 hours later: wire removed then
protamine given

•If unable to deliver

covered stent,
prolonged balloon
inflation can achieve
hemostasis

•Heparin reversal
should be delayed until
after equipment
removal from coronary
arteries
Final tip 1: Watch the pressure!
Tip 2. Pericardiocentesis with fluoroscopic guidance
Tip 3: Echo contrast to
confirm sealing
 TIP 4
Perforation in the post
CABG patient can be a
lethal complication –
TREAT IT IMMEDIATELY!
Wilson et al. CCI 2015;86:407–41
 Lessons

1. Perforation: Universal
algorithm

2. Know your covered

stents

3. Prolonged balloon
inflations

4. Do not reverse heparin

5. Prior CABG: treat early!