4 Comments

23 Nov 2018

Other coronary interventions Complications

Case study: distal perforation coils Type V perforation

Complications - Coronary perforation

Consult this case study on using distal perforation coils, a 76-year-old male patient with dyslipidemia and hypertension.

Part 1 - Presentation & procedure

Clinical presentation

Male, 76-year old
Risk factors:
- Dyslipidemia
- Hypertension
History:
- Previous PCI of obtuse marginal with DES
Presentation:
- Stable angina CCS II
- ECG normal
- Treadmill test positive

Angiography assessment

Left coronary artery without signicative stenosis, patent OM stent.

A tortuous right coronary artery, mid-part stenosis Risk evaluation: EuroSCORE (mortality logistic) = 0.5 % and SYNTAX score = 3

PCI of the mid-RCA

Guidewire positioning

Pre-dilatation with semi-compliant balloon 2.5 x 15mm at 10 ATM

Accordion phenomenon with guidewire

Implantation of DES 2.5x15 mm at 12 ATM

Post-dilatation

Result after stenting

Post-dilatation with NC balloon at 18 ATM - Where is the wire?

Result after NC balloon inflation

The guidewire moves freely

Result without guidewire: evidence of distal perforation

Part 2 - Perforation management

Management of Type V perforation

Re-wire with guide wire

Rapid balloon inflation

Please also consult Link 1 on inflate balloon for further reading.

Decision to coil: microcatheter positioning

1 coil injected through microcatheter

For further reading, please consult Link 5 - Coil embolization

Result after distal coils

Result after 1 coil: distal RCA not totally occluded

2nd coil injected

Final angiographic result

Distal RCA totally occluded

Part 3 - Reflection

Strategy

Always keep an eye on the distal part of your wire
Look at the movement of your distal wire
Retrieve / Retract the wire a little for the final injection
Do not retrieve your wire before a double check of potential perforation

Avoid perforation

Take care with distal guidewire position
Before a final injection, retrieve the wire a little from a distal position

Perforation

Balloon inflation
Consider coil after several minutes of balloon inflation
Know your material

4 comments

Mansoor Nasir 11 Jun 2017

The appearance seems to be intra-myocardial heamatoma rather than free perforation. No change in size after multiple injections. No clinical, heamodynamic and echo-cardiographic findings were mentioned, in the absence of which treatment is that of a angiographic finding rather than of patient. Wait and see anyone?????

ramesh sankaran 22 Jun 2017

BALLOON INFLATION OR USE FINE CROSS MICROCATHER TO DELIEVER GLUE OR BLOOD CLOT TO SEAL THE PERFORATION

eric guis 29 Jun 2017

ERIC GUIS 26 JUN 2017: THE COIL SEEM TO BE IN THE DISTALITY OF THE MARGINAL BRANCH

Solomon Asgedom 31 Jul 2017

There is no change on subsequent images and there is no obvious contrast in pericardium and it looks confined to myocardium. Is there any benefit of the coils ?

Mansoor Nasir 11 Jun 2017
The appearance seems to be intra-myocardial heamatoma rather than free perforation. No change in size after multiple injections. No clinical, heamodynamic and echo-cardiographic findings were mentioned, in the absence of which treatment is that of a angiographic finding rather than of patient. Wait and see anyone?????
ramesh sankaran 22 Jun 2017
BALLOON INFLATION OR USE FINE CROSS MICROCATHER TO DELIEVER GLUE OR BLOOD CLOT TO SEAL THE PERFORATION
eric guis 29 Jun 2017
ERIC GUIS 26 JUN 2017: THE COIL SEEM TO BE IN THE DISTALITY OF THE MARGINAL BRANCH
Solomon Asgedom 31 Jul 2017
There is no change on subsequent images and there is no obvious contrast in pericardium and it looks confined to myocardium. Is there any benefit of the coils ?