Abstract: Aims. Coronary artery perforation is a rare but potentially serious complication of percutaneous coronary intervention (PCI). Clinical manifestation and prognosis of patients depend on the severity of the complication, the occurrence of tamponade, and the methods of treatment. A special type of perforation is caused by damage to the distal segment of the coronary vessel by guidewire. This type of perforation is mostly connected with subacute clinical presentation. The treatment can be difficult, especially when prolonged balloon inflation is not efficient. The aim of the article is to present a balloon fragment technique as a treatment method for distal vessel perforation. Methods. The method of treating distal perforation, which we presented at EuroPCR 2019, involves embolization of a perforated vessel with a cut part of balloon catheter. Six patients are included in this registry; only 1 truncated proximal balloon fragment was enough to effectively embolize the perforated vessel in 4 patients, while 2 balloons were required in 1 patient and 3 balloons were required in 1 patient. Conclusion. Compared with other methods, this technique is an easy, cheap, and effective treatment for distal vessel perforation. The described method is available in every catheterization laboratory and does not require expensive equipment or exceptional operator experience.
J INVASIVE CARDIOL 2020;32(12):E370-E372.
Key words: coronary perforation, PCI, stentgraft, tamponade
Coronary artery perforation is a rare (0.2%-0.6%) but potentially serious complication of percutaneous coronary intervention (PCI). It is characterized by a rupture of the arterial lumen and blood extravasation into the myocardium or pericardium.1
The modified Ellis classification is used to stratify coronary perforations: type I = extraluminal crater with no linear contrast extravasation that suggests dissection; type II = myocardial or pericardial blushing; type III = frank contrast medium extravasation into the pericardium; and type IV = perforation with contrast extravasation directly into the left ventricle, to the coronary sinus or other vascular areas.2 We occasionally observe another mechanism of perforation, ie, distal coronary vessel perforation (DCVP). This damage occurs during deep penetration of the guidewire, which is often terminated with a loop shape into the small peripheral side branch.
This type of perforation is associated with specific clinical manifestation. Initially, extravasation of contrast at the end of the vessel observed on angiography is asymptomatic, without pericardial fluid in the echocardiogram. The rate of fluid build-up in the pericardium depends on the rate of extravasation. In untreated cases, we observe a subacute pericardial tamponade associated with slow pericardial blood extravasation over 10 minutes or more after perforation. This type of perforation can create diagnostic and therapeutic difficulties, as the patient is often already out of the catheterization laboratory.
Method of implementation and the case registry. Management of DCVP with part of a balloon catheter is illustrated in Figure 1 and Figure 2. The technical steps are as follows: (1) immediately apply prolonged balloon inflation (PBI) to stop extravasation; (2) cut the previously expanded balloon in the middle of the length between the markers; (3) place the proximal fragment of the umbrella-shaped balloon on a guidewire; (4) place another uninflated balloon (the “pushing balloon”) on the same wire; and (5) push part of the cut balloon to the distal part of the vessel using the second pushing balloon and place it in the distal vessel to embolize before the place of perforation.
If the perforation cannot be closed with one part of the balloon, the operation can be repeated with the next bigger size of cut balloon.
We performed 2983 PCIs in our cath lab from August 2017 to January 2020 at the Department of Cardiology, 1st Military Hospital in Lublin Poland, of which 9 (0.3%) were complicated with DCVP. Three patients were successfully treated with PBI, but PBI was insufficient in 6 patients; the vessels were embolized with a fragment of balloon catheter.
The baseline clinical characteristics and PCI data are shown in Table 1 and Table 2. In 4 cases, only 1 cut balloon per case was used to close the vessel. Three of the described cases were associated with tamponade and pericardiocentesis. No patient has died.
There are several management options for DCVP. PBI — the obvious first step — is often insufficient (54.5%); however, it provides time to prepare another treatment method. If PBI is unsuccessful, the next step is to try to close the perforation by embolizing the artery. Treatment of perforation using various materials, such as coils, thrombin, clot, fat, glue, or spongostan, is described. The use of microcoils is a commonly used option; however, the cost, need for microcatheters, and limited operator experience remain certain limitations of this method. Other treatment options, such as thrombin, clot, or fat embolization,3,4 can be problematic due to operator inexperience with the necessary techniques. Glue embolization, which is a method used mainly in neuroradiology, can be associated with potential serious complications, such as trapped microcatheter in a coronary vessel. Spongostan is an interesting option to treat perforation, especially in a side branch. After blocking the main vessel with an expanded balloon, spongostan can be injected to the side branch by an over-the-wire balloon to produce transient embolization and even restoration of branch blood flow after several hours. Another option to treat side-branch perforation is covered stent implantation. Rescue implantation of the stent-graft into the main vessel is possible; however, the cost is blocking the blood flow to the side branch.
Compared with other methods, this technique is an easy, cheap, and effective treatment for DCVP. Moreover, this method is available in every cath lab and does not require expensive equipment or exceptional operator experience. The balloon fragment technique does have some limitations. Generally, it is a “one-way ticket only” — we can push forward a cut balloon using a pushing balloon, but cannot easily move the cut balloon backward out of the coronary vessel; however, it is possible. If we predict problems with delivery of the balloon — for example, because of calcifications or vessel tortuosity — we can use a guide extension or second wire. Another aspect is the choice of cut balloon size. The size of the balloon is important, because a balloon that is too small will not close the perforation and a balloon that is too large can cause proximal embolization of the vessel. For good visualization of the cut fragment, balloon catheters with 2 markers should be selected.
DCVP is an etiologically and clinically different type of perforation that requires specialized treatment. The balloon fragment technique is easy, cheap, and effective, and is available in every catheterization laboratory. It does not require expensive equipment or exceptional operator experience.
From the Department of Cardiology, 1st Military Hospital in Lublin, Lublin, Poland.
Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.
The authors report that patient consent was provided for publication of the images used herein.
Manuscript accepted May 7, 2020.
Address for correspondence: Bartosz Zięba, MD, 1st Military Hospital in Lublin, Lublin, Woj. Lubelskie, Poland. Email: firstname.lastname@example.org
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