the nightmare in cath lab: early identification and emergent correct treatment

The Nightmare in Cath Lab: The Nightmare in Cath Lab: Early Identification and Emergent CEarly Identification and Emergent C

orrect Treatment orrect Treatment

Yuejin Yang MD, PhD, FACC, FESCYuejin Yang MD, PhD, FACC, FESC

Cardiovascular Institute and Fu-WaiCardiovascular Institute and Fu-Wai

Hopital, CAMS & PUMCHopital, CAMS & PUMC

The 11th Nanjing Course on Cardiac Revascularization & ACS, in conjunction with CAP-CCBC, Nanjing, Sept. 13, 2013

The 11th Nanjing Course on Cardiac Revascularization & ACS, in conjunction with CAP-CCBC, Nanjing, Sept. 13, 2013

Numbers of PCI in Each Year @ Fu Wai

415 618 9211386 1605

19672555

32823821

47785148

6599

8050

10649

3 3 13 186 374706

12472018

2659

38404326

5623

7229

9673

0

2000

4000

6000

8000

10000

12000

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Total PCI Radial

2011: PCI case No: 10649, Radial 90.8%2011: PCI case No: 10649, Radial 90.8% （（ 9673/10649)9673/10649)

TRI from <1% in 1998 to >90% in 2011 with the very low mortality rate of just 0.05% in elective PCI

TRI from <1% in 1998 to >90% in 2011 with the very low mortality rate of just 0.05% in elective PCI

The Impact of PCI on CHD

Effective in:– Interventional revascularization

– Cure the patients with CHD

Safety problems:– Severe complications

Hurt the patients

Even leading to death of the patients

If identification late and treatment

improperly or correctively

– Or nightmare in the Cath Lab

Nightmares in Cath Lab ?

Severe PCI complications

Resulting in severe consequences

Even leading to:

– death

– MI

– Emergency CABG

Category of PCI ComplicationsCoronary

Puncture site

Others

Stent related (BMS, DES)

TRI related

Medication related:– Antiplatelet and anticoagulation– Contrast media

Hypersensitivity (anaphylactic shock)

AKI

Coronary Complications

Coronary injury leading to:

Severe dissection

Acute closure

Rupture

Perforation

Thrombosis

Thrombotic embolism

Access Site Complications

Bleeding

Big hematoma

Post-peritoneal hematoma

A-V fistula

Vessel injury (dissection)

Thrombosis

Thrombo-embolism

Infection

Other Complications

ComorbiditiesSystemic thrombo-embolismsMicrovascular embolisms

( thrombosis and air)StrokeBrain hemorrhageGI bleedingBleeding on other organsVagal reflex and hypotensionHemodynamic instability

Stent Related Complications

Stent thrombosisAcute (<24 hrs)

Subacute (1-30 ds)

Late (1-12 ms)

Very late (>1 yr)

Definite

Probable

Possible

Stent dislodge

Stent dystroy

TRI Related Complications

Radial artery closureVessel injury by wire and hematoma along with the route

Forearm hematoma and osteo-compartment syndromeNeck hematomaMediastinum hemotomaChest hemotoma or pleural bleedingStroke

Aortic dissection

Medication Related Complications

Dual antiplatelet and antithrombin therapyBleeding ( brain, GI, fundus, gum, et al)

Hemotoma

HIT due to heparin

Plateletcyclopedia due to 2b/3a inhibitor at al

WBC decrease

Hypersensitivity

Contrast media CKD

Allergy even allergic shock

Clinical Nightmares in Cath Lab

CV collapse

Big coronary (including sidebranch) acute closure

Coronary rupture

Severe no-reflow phenomenon

Cardiac tapenade

Severe allergic shock

Stent thrombosis

Brain hemorrhage

stroke

Case 1: CV Collapse after CAA in Pts with STEMI (IPW)

Mr. Zhang Zhengang, M 66 yrs, 810865

STEMI (IPW) for 4 hrs, 2012-6-13

CV collapse after LCA A

Bp continually declined before RCA A

Continuous CPR, IABP, Intubation preparation

IABP pulled out during CPR

Left femoral approach to RCA A

TIMI flow II with 95% stenosis

Case 1: CV Collapse after CAA in Pts with STEMI (IPW)

TIMI flow back to III after 1st aspiration

Residual stenosis 90%

After 2nd aspiration, residual stenosis 80%

No PTCA, No Stent

CCU stay for 10 days

CABG suggested, but 1-2 Mons later needed

Pts discharged on his own demand

Baseline LCA A

LAD & LCX CTO Poor local collateral circulation

CPR and RCA A

Bp declined before RCAA LFA RCAA under CPR

Final Results• After 2nd aspiration,

TIMI flow III• RCA to LAD collateral

circulation• Residual stenosis 80%• IABP via LFA • Pts calmed,

hemodynamics stable• Sent to CCU

Case 2: Severe Complication – LM dissection leading to acute closure

Mr. Song Chen Wu, M 40 yrs, 841948

2013-2-26

XB-LAD Guiding

LM dissected and acute closure

Baseline CAA

Guiding engaged uncoaxially LM & LAD dissected severely

LAD closure

LAD acute closure & IABP support, Wiring

Guiding changed to Judkins L3.5

Rescue Successful

Wiring successful & ballooning TIMI flow III

Stenting

Final Results

Case 3 RCA Rupture after Post-stent Kissing

Mr. Wang Yu min, M 54 yrs, 819648

2012-9-19

Admitted due to ACS

Baseline CAA

LAD 80%, Dia 80%, distal LCX 80%

Distal RCA & Bifurcation 90%

PTCA and Stenting

After PTCA After Stenting （ 2.75 × 24mm ）

Kissing Ballooning

1st Kissing OK 2nd Kissing with high pressure of 12atm

RCA Rupture

RCA Rupture Balloon occlusion, pericardial centesis, cardiac surgeon consulted

Covered Stent

Covered stent Almost sealed

Final Results ?

40 Minutes Later

Massive clot showed in pericardium & stent leakage at distal vessel

Obvious contract media stay in pericardial cavity

Re-sealed

Another covered stent, JR guiding very deep seating to seal the leakage

Covered stent deployed & leakage sealed with the price of PDA acute closure

Final Results

No sign of pericardial effusion

Pericardial Cine Check

No sign of pericardial effusion

Case 4: LAD&Dia two stent complicated with ST

Mr. Ni Xiang ren, M 45, 819127

2012-8-22

Admitted due to ACS

Baseline CAA

LAD 90%, big Dia 90%, LCX 90% Distal RCA 100% with collateral circulation from LAD

Two Stent Strategy

Rewiring & Reballooning Kissing ballooning

Final Results

OK OK

3 Hrs Later, Chest Pain with ST Elevation

Stent total occlusion due to AST Ballooning

Final Results

TIMI Flow OK, LCX 100% Flow sluggish without emptying, CV Collapse happened, CPR

Case 5: Acute Closure of Big RCA

Mr. Shang Feng yi, M 56 yrs, 838552

2013-1-13

Big RCA very tortuous

Acute closure due to wire injury

Baseline CAA

LAD & LCX OK Big RCA very tortuous with tight lesion

RCA Closure and Rescue

RCA acute closure due to BMW injury

IABPPilot 50 wiring & ballooning

Stenting

Big RCA opened Stenting

Final Results

OK, No distal dissection RCA TIMI flow III

Case 6: RCA Stenting Complicating with Side Branches Acute Closure

Mrs. Cao Wen hua, F 64 yrs, 782315

2012-1-10

CABG for 5 yrs

LAD & LCX 100%

RCA In-stent stenosis & occlusion with big side branches

Baseline CAA

LAD & LCX 100% RCA In-Stent 100% involving two PDA branches

RCA PCI

Ballooning without side branches wire protection

Two big branches acute closure

RCA PCI

Hemodynamic unstableIABP & Temporary Pacemaker

Two side branches TIMI flow I+

One weeks later, Pts died of SCD

Case 7: High risk pts without hemodynamic support

Mrs. Zhang Xiu zhen, F 80 yrs, 713486

2010-2-8

Primary PCI for STEMI

High risk Pts without hemodynamic support

Baseline CAA

LAD 100% RCA 70%

Ballooning

Pre-stent ballooning After ballooning, TIMI flow I& CV collapse happened

IABP & Reballooning

IABP & Reballooning TIMI flow remained I

Take Home Messages

Always keep in mind:

– There are some possibilities of complication

when we do every PCI cases

– Early identification and emergent correct

management can avoid the nightmare in the

Cath. Lab.

WelcomeWelcome Attend China Heart Conference (IHF2014)Attend China Heart Conference (IHF2014) ：：

6th6th international TR Coronary Therapeutics (T international TR Coronary Therapeutics (TRCT)RCT)

Chaired byChaired byYue-Jin Yang MD. PhD. FACCYue-Jin Yang MD. PhD. FACC

Co-Chaired byCo-Chaired byDr. SaitoDr. Saito

Dr. kiemeneijiDr. kiemeneijiCNCC, CNCC, 2014/08/08-11, Beijing, China2014/08/08-11, Beijing, China

Thank You for Your Thank You for Your Attention !Attention !