ABSTRACT: Deployment of a polytetrafluoroethylene-covered stent is a useful option to seal coronary perforation. However, the high profile and low flexibility compromise its deliverability. To facilitate stent delivery, deep-vessel intubation with a 5 Fr guiding catheter through a 6 or 7 Fr guiding catheter (mother-and-child catheter) has been used. This case report describes a successful deployment of a polytetrafluoroethylene-covered stent through a 5 Fr Heartrail ST01 guiding catheter (Terumo) to seal coronary perforation.
J INVASIVE CARDIOL 2012;24(9):E199-E201
Coronary perforation is a rare but devastating complication of percutaneous coronary intervention (PCI) with potentially fatal outcome.1-6 Rapid sealing of coronary perforation is required especially when the patient has perforation with continuous extravasation. Deployment of a polytetrafluoroethylene (PTFE)-covered stent is a useful option to seal coronary perforation.2 However, the high profile and low flexibility compromise its deliverability especially in small, calcified, or tortuous vessels.7 Deep-vessel intubation with a 5 Fr guiding catheter through a 6 or 7 Fr guiding catheter (mother-and-child catheter) may be used when stent delivery is unsuccessful using conventional techniques.8-10 However, it was previously unknown whether or not a PTFE-covered stent passes through a 5 Fr guiding catheter. This case report describes a successful deployment of a PTFE-covered stent through a 5 Fr guiding catheter to seal coronary perforation.
Case Report. A 51-years-old male patient on diabetes-related dialysis was admitted due to exertional angina. Coronary angiography revealed chronic total occlusion of the mid-left anterior descending coronary artery (LAD) (Figure 1A), a 90% stenosis in the mid-left circumflex artery, and 90% diffuse narrowing in the right coronary artery. He refused to undergo recommended coronary artery bypass surgery. The patient was referred for PCI. The right coronary artery lesion was treated successfully.
One month later he was readmitted for PCI to the LAD and the left circumflex artery. A 7 Fr EBU 3.5 guiding catheter (Medtronic) from the right femoral artery was positioned at the left main ostium. PCI to the left circumflex artery was performed successfully. PCI to the LAD was then attempted. A 0.014” ULTIMATEbros 3 guidewire (Asahi Intecc) was successfully crossed into the distal LAD after a failed attempt with a 0.010” Athelete eel slender guidewire (Japan Lifeline). Predilatation using a 2.0-mm OZMA balloon catheter (Nipro Medical) at 12 atm and a 2.75-mm LIFESPEAR balloon catheter (Japan Lifeline) at 14 atm was performed. Intravascular ultrasound was then performed. It demonstrated that the minimal and maximal vessel diameter of the target lesion were 3.2 mm and 4.1 mm, respectively. A 33 mm Cypher select plus stent (Johnson & Johnson) premounted on a 3.0 mm balloon catheter was deployed in the mid-LAD using an inflation pressure of 18 atm. Coronary angiography revealed massive coronary perforation at the distal edge of the stent (Figure 1B). His blood pressure suddenly went down. Cardiopulmonary resuscitation was started and percutaneous cardiopulmonary support was initiated. To seal the perforation, repeated inflation of the Cypher stent balloon at 6 atm for 15 minutes and deployment of a 28-mm Xience V stent (Abbott) premounted on a 2.5-mm balloon catheter at 8 atm were performed. However, neither could seal the perforation. We attempted delivery of a 16-mm PTFE-covered stent (JOSTENT Graftmaster, Abbott) premounted on a 3.0 mm balloon catheter. It would not advance beyond the proximal edge of the Cypher stent. The operator tried to withdraw it but it did not move. Thus the PTFE-covered stent was deployed in the segment proximal to the Cypher stent. We attempted delivery of another 16-mm PTFE-covered stent premounted on a 3.0-mm balloon catheter but it failed. A 5 Fr Heartrail ST01 guiding catheter (Terumo) was inserted into the 7 Fr EBU 3.5 guiding catheter (mother-and-child catheter). The 5 Fr guiding catheter was introduced without difficulty until the perforation site along the shaft of the 2.75 mm LIFESPEAR balloon catheter inflated in the stent (Figure 1C). The PTFE-covered stent was then advanced through the 5 Fr guiding catheter. The operator felt a slight resistance but could deliver the stent to the perforation site. It was deployed at 12 atm and sealed the perforation (Figure 1D). Postdilatation using a 3.5 mm LIFESPEAR HP balloon catheter at 12 atm was performed. A 30-mm Endeavor sprint stent (Medtronic) premounted on a 2.5-mm balloon catheter was deployed in the distal LAD. The final coronary angiography showed a good result (Figure 1E).
Discussion. The reported incidence of coronary perforations ranges from 0.1% to 3.0%.1-6 Women and the elderly appeared to be at higher risk of perforation.1 Prolonged balloon inflation, reversal anticoagulation, discontinuation of IIb/IIIa inhibitors if used, and platelet transfusion if needed may be performed to seal perforation.1,2,7 However, the conventional management often fails to seal perforation especially when it is severe (ie, Type III: extravasation through frank [≥1 mm] perforation).1,2 Before PTFE-covered stents were available, type III perforations were associated with a high incidence of major adverse events (death, 19%; emergency bypass surgery, 63%; Q-wave myocardial infarction, 15%; cardiac tamponade, 63%).1
Covered stents are a unique tool to seal perforation. Briguori et al2 demonstrated a high success rate (91%) for sealing type III coronary perforation with PTFE-covered stents. In their study, clinical outcomes were compared between patients treated with and without PTFE-covered stents for coronary perforation that could not be sealed by conventional management. The PTFE-covered stent group had a lower incidence of non-Q-wave myocardial infarction (0% vs. 47%, p=0.005), cardiac tamponade (8% vs. 82%, p<0.001), blood transfusion (18% vs. 88%, p<0.001), and bypass surgery (18% vs. 88%, p<0.01).2
The PTFE-covered stent is a balloon-expandable, slotted-tube stent manufactured by sandwiching a layer of PTFE between 2 stents.7 It has high profile and low flexibility that make its delivery difficult especially in small, calcified, or tortuous vessels. For delivery of a PTFE-covered stent, a 7 Fr guiding catheter is recommended by the manufacture.7 A 6 Fr guiding catheter might be used with 2.75 mm-3.5 mm stents.7 Deep-vessel intubation with a 5 Fr guiding catheter through a 6 or 7 Fr guiding catheter (mother-and-child catheter) may be used if the operator failed to advance a stent into the target lesion.8-10 To the best of our knowledge, this is the first case with delivery of a PTFE-covered stent through a 5 Fr Heartrail ST01 guiding catheter. We tried in vitro delivery of two 16-mm PTFE-covered stents premounted on a 3.0 mm balloon catheter through two 5 Fr Heartrail ST01 guiding catheters as the child catheter and a 6 Fr EBU 3.5 guiding catheter as the mother catheter. The guiding catheters were immersed in water. Either PTFE-covered stent passed through both 5 Fr guiding catheters (Figure 2). However, it should be mentioned that there was some resistance during stent delivery. Thus it may be important to advance a PTFE-covered stent slowly. We also tried in vitro delivery of a 16-mm PTFE-covered stent premounted on a 3.0 mm balloon catheter through a 5 Fr DIO catheter (Goodman). It would not advance through the DIO catheter. We did not try it through a 4 Fr Kiwami catheter (Terumo) or a 4.5 Fr CoKatte catheter (Asahi Intecc).
Some limitations should be noted to use a 5 Fr guiding catheter for delivering a PTFE-covered stent. In the present case, a 16 mm PTFE-covered stent premounted on a 3.0 mm balloon catheter was used. Larger diameter or longer PTFE-covered stents might not pass through a 5 Fr guiding catheter. Although the in vitro experiment using a 6 Fr guiding catheter as the mother catheter showed that a PTFE-covered stent passed through a 5 Fr guiding catheter, a 7 Fr guiding catheter was used in the present case. Furthermore, if the operator is unfamiliar with the mother-and-child catheter system, it may be difficult to establish it quickly especially in the emergency situation.
A 5 Fr guiding catheter through a 7 Fr guiding catheter (mother-and-child catheter) may be used if deliver of a PTFE-covered stent is unsuccessful using conventional techniques.
- Ellis SG, Ajluni S, Arnold AZ, et al. Increased coronary perforation in the new device era. Incidence, classification, management, and outcome. Circulation. 1994;90(6):2725-2730.
- Briguori C, Nishida T, Anzuini A, Di Mario C, Grube E, Colombo A. Emergency polytetrafluoroethylene-covered stent implantation to treat coronary ruptures. Circulation. 2000;102(25):3028-3031.
- Ajluni SC, Glazier S, Blankenship L, O'Neill WW, Safian RD. Perforation after percutaneous coronary interventions: clinical, angiographic, and therapeutic observations. Cathet Cardiovasc Diagn. 1994;32(3):206-212.
- Bittl JA, Ryan TJ Jr, Keaney JF Jr, et al. Coronary artery perforation during excimer laser coronary angioplasty. The percutaneous Excimer Laser Coronary Angioplasty Registry. J Am Coll Cardiol. 1993;21(5):1158-1165.
- Holmes DR Jr, Reeder GS, Ghazzal ZM, et al. Coronary perforation after excimer laser coronary angioplasty: the Excimer Laser Coronary Angioplasty Registry experience. J Am Coll Cardiol. 1994;23(2):330-335.
- Javaid A, Buch AN, Satler LF, et al. Management and outcomes of coronary artery perforation during percutaneous coronary intervention. Am J Cardiol. 2006;98(7):911-914.
- Romaguera R, Waksman R. Covered stents for coronary perforations: is there enough evidence? Catheter Cardiovasc Interv. 2011;78(2):246-253.
- Hayashida K, Louvard Y, Lefèvre T. Transradial complex coronary interventions using a five-in-six system. Catheter Cardiovasc Interv. 2011;77(1):63-68.
- Takahashi S, Saito S, Tanaka S, et al. New method to increase a backup support of a 6 French guiding coronary catheter. Cathet Cardiovasc Interv. 2004;63(4):452-456.
- Shaukat A, Al-Bustami M, Ong PJ. Chronic total occlusion--use of a 5 French guiding catheter in a 6 French guiding catheter. J Invas Cardiol. 2008;20(6):317-318.
From the 1Department of Cardiovascular Science and Medicine, Chiba University Graduate School of Medicine, Chiba, Japan and the 2Department of Cardiology, Kimitsu Central Hospital, Kisarazu, Japan.
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.
Manuscript submitted March 22, 2012, provisional acceptance given April 9, 2012, final version accepted April 23, 2012.
Address for correspondence: Yoshihide Fujimoto, MD, Department of Cardiovascular Science and Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, Chiba 260-8677, Japan. Email: email@example.com