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ROSLI Mohd Ali
Head
Department of Cardiology
National Heart Institute
Kuala Lumpur
PCI Complications
BX Velocity Stent 3.5 x 18 at 16 Atm
Peak CK – 7797 u/L
Mid LAD stenosis 2002
58 yr lady
Direct stenting with AVE S7 3.0 x 24 mm
What would you do?
PCI Procedural Success
1. Angiographic (anatomical) success
2. Without clinical complications
Angiographic (anatomical) success:
• minimal luminal diameter < 10% stenosis
• TIMI 3 flow
Without clinical complications
• MACE (major adverse cardiac events)
• MACCE (major adverse cardiac &
cerebrovascular events)
PCI Clinical Complications
MACE (major adverse cardiac events)
composite of
death,
MI or
emergency revascularisation
MACCE (major adverse cardiac & CV events)
composite of
death, MI, emergency revascularisation or
stroke
Classification of Complications
Category Mechanism Coronary injury acute/threatened closure
no reflow phenomenon
perforation
retained equipment
arrhythmia
Non-coronary iatrogenic aortic dissection
Injury peripheral neovascular injury
embolisation (stroke/limb ischaemia)
nephropathy
radiation injury
Systemic event vasovagal reaction
anaphylaxis
haemorrhage
acute pulmonary oedema
sepsis
PCI Complications Rates
Gruentzig original 50 pts 1977 14 %
NHLBI PTCA Registry 1985 6.6 %
New York State PCI Registry 1999 – 2006
Overall complications 3.36 %
Mortality
in Cath. Lab 0.047 %
at one month 0.6 %
PCI Complications Rates:
NY State Registry 1999 – 2006 n - 23,339 procedures
Causes %
Death 1 mo post PCI 0.6
Death in cath. lab 0.047
Stroke 0.29
Cardiac perforation 0.29
Any MI 0.74
Emergent surgery 0.15
Stent thrombosis at 1 mo 0.53
Presumed stent thrombosis 0.82
Renal failure 0.28
Haemodialysis 0.17
Retroperitoneal bleed 0.18
Vascular complication & bleeding 0.79
1 mo composite with ST 1.8
1 mo composite without ST 1.58
Any Complication 3.36
PCI Complications
Prevent, Anticipate, Recognise & Manage
Patient Factor:
Frailty, old age
Co-morbid conditions eg renal failure, DM, COPD, PVD
Cardiogenic shock
Obesity
Anticoagulation
Lesion Factor:
LMS disease
Multivessel disease
Diffuse lesions
Thrombosis
CTO
Calcified
PCI Complications
Prevent & Manage
To reduce mortality & morbidity
Drs & Allied Staff
• knowledgeable
• discussion about patient & procedure
• have devices ready
• focus on patient during procedure
• willing to inform of any changes
hemodynamic, ECG, patient’s condition
angiographic abnormalities
Long total prox. - distal LAD occlusion
42 yr
old man
Following 2 Drug-eluting Stents
2 GDC coil embolization
Perforation
If suspect tamponade, confirm with
echocardiogram.
Potential treatment
Perforation
• Long balloon inflation
• Reverse heparin
protamine sulphate 1 mg per 100 units heparin
• Persistent perforation
distal – coil embolisation, glue, fat tissue
mid - covered stent, sandwich stents
emergency surgery
CARE with Gp IIb/IIIa inhibitor !!
Perforation
Perfusion balloon (prolonged inflation time)
Site proximal / mid:
Covered stent
Site distal:
Coil
21 July 2011, 10:38:28 am, IJN
248 min fr. onset of chest pain
In cardiogenic shock. SBP 80 mmHg
302194 (6 Sept 13)
54 yr old man
Anterior STEMI D3
TRI
Castillo 2 6 Fr
(diagnostic)
Causes of Slow Flow?
1. Distal dissection
2. Spasm
3. Distal embolization
4. Poor distal run-off (loss of branches)
5. High LVEDP
6. Hypotension
7. Wire biasness
Injection through thrombuster
Adenosine bolus
Through thrombuster
(went to transient
standstill)
+ NTG
POBA 1.5 x 15 mm
AL1 6Fr
Conquest Pro wire
Runthrough Floppy (anchor wire)
Thrombotic lesions?
52 yr old man with post-infarct angina
1 wk after inferior MI
PCI 3rd April 2007
Aspirated with Export cath 7F
Balloon dilatation
3. Thrombus
PCI Cases: when do we stop?
1 week of sc enoxaparin 10th April ‘07
Continued with oral anticoagulation
Ischaemic test planned in the future
3rd April ‘07
Angiojet Thrombectomy Device
Bernoulli Principle
Where the velocity is the greatest,
the pressure is the lowest
Iatrogenic Coronary Thrombosis
Avoiding Risk
keep equipment dwell time to a mininum
wipe all exteriorised equipment before
reintroduction
Flush all introducers & catheters regularly
Heparin before PCI
weight adjusted dose
(70 units/kg – check ACT every 30 min
100 units/kg – ACT after one hour)
Check ACT when time arrives
Stented LMS to LAD
3.5 mm
DEB Sequent Please
LMS to LAD
3.0 x 20 mm
Sequent Please
3.0 x 30 mm
Kissing
LAD 3.5 mm
LCx 3.0 mm
Stent
3.5 x 12 mm
Radial artery damage - Perforation:
Incidence 0.1 – 1%
Tortuous and looping
Spasm
Anomalous anatomy
Hydrophilic wires
Catheters
Often a matter of feel
If in doubt:
Fluoroscopy &
take an angiogram!
Put in a long sheath
Complications
of the Radial Approach
Radial artery damage- Perforation:
MIDFOREARM HAEMATOMA
Direct Stenting in
Hugging Fashion
Long Wallstents
10 mm in diameter
Hypotensive
SBP dropped from 120 – 130 to 70 mmHg
Patient getting restless
BP dropped whenever balloon deflated
Forgot to bring Jomed covered stent graft !!
Saved !! Wallstent graft 11 mm x 50 mm
No 11 F sheath !!
BP stabilized
Transfused 4 pints of pack cells
CT scan – blood in pelvic cavity
Discharged a few days later
Conclusions
Can’t avoid complications!
Prevent & manage them well
• Select patient & lesion well.
• Anticipate problems & plan strategy well
• Good guiding catheter
• Good angiographic views
• Know your equipment well
• Have them available
• Keep the procedure as simple as possible
• Know your own limitations
• Know when to stop
• Learn from one’s own & other’s mistakes
You are part of the team!!
