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J A C C : C A R D I O V A S C U L A R I N T E R V E N T I O N S V O L . 1 1 , N O . 1 8 , 2 0 1 8

ª 2 0 1 8 B Y T H E AM E R I C A N C O L L E G E O F C A R D I O L O G Y F O UN DA T I O N

P U B L I S H E D B Y E L S E V I E R

STATE-OF-THE-ART REVIEW

A Practical Approach to theManagement of Complications DuringPercutaneous Coronary Intervention
Francesco Giannini, MD,a,* Luciano Candilio, MD,a,b,* Satoru Mitomo, MD,a Neil Ruparelia, MD,a Alaide Chieffo, MD,a
Luca Baldetti, MD,a Francesco Ponticelli, MD,a Azeem Latib, MD,a Antonio Colombo, MDa

ABSTRACT

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Percutaneous coronary intervention relieves symptoms in patients with chronic ischemic heart disease resistant to

optimal medical therapy and alters the natural history of acute coronary syndromes. However, adverse procedural

outcomes may occur during the intervention. Knowledge of possible complications and their timely management

are essential for the practicing cardiologist and can be life-saving for the patient. In this review, the authors

summarize potential complications of percutaneous coronary intervention focusing on their practical management.

(J Am Coll Cardiol Intv 2018;11:1797–810) © 2018 by the American College of Cardiology Foundation.

P ercutaneous coronary intervention (PCI) iscurrently indicated for the management ofpatients presenting with acute coronary

syndrome and in individuals with chronic stableangina that is refractory to optimal medical therapy.Advances in devices, stent design, adjunctive tech-nology, development of more potent and effectiveantiplatelet therapy, and judicious use of PCI areincreasing the safety of the procedure. However,major periprocedural complications during PCI stilloccur. These problems can be related to the accesssite, intubation of the coronary artery ostia, or theintervention itself. In the current review, we describepossible complications during PCI, focusing onthose occurring in the context of coronary intubationand target vessel or site intervention, including coro-nary perforation, abrupt vessel closure (AVC), stentdeformation (and loss), wire fracture (and loss),device embolization, and rotational atherectomyburr entrapment. Management of these complicationsis predominantly based on operator experience and

N 1936-8798/$36.00

m the aUnit of Cardiovascular Interventions, IRCCS San Raffaele Scien

partment, Hammersmith Hospital, Imperial College, London, United King

ationships relevant to the contents of this paper to disclose. *Drs. Giannin

joint first authors.

nuscript received January 7, 2018; revised manuscript received May 7, 20

small case series with limited available guidancein the literature on account of their relative rarity.Therefore, we intend to provide recommendationsrelating to the practical aspects of their timely recogni-tion and treatment.

CORONARY PERFORATION

Coronary perforation has an estimated incidence of0.5% (1,2) and is associated with a 13-fold increase ofin-hospital major adverse events and a 5-fold increaseof 30-day mortality (2). It is most commonly causedby balloon or stent mismatch (oversizing of the dila-tation catheter, particularly when the balloon-arteryratio is >1.2:1 or when semicompliant balloons areinflated at very high pressure) (3), but can occasion-ally occur with the use of an appropriately sizedcatheter in the context of extensive dissection or lackof vessel wall integrity, occur in the presence ofarterial calcification, or be caused by inadvertentcoronary wire tip migration. Other factors associated

https://doi.org/10.1016/j.jcin.2018.05.052

tific Institute, Milan, Italy; and the bCardiovascular

dom. The authors have reported that they have no

i and Candilio contributed equally to this work and

18, accepted May 29, 2018.

https://doi.org/10.1016/j.jcin.2018.05.052

http://crossmark.crossref.org/dialog/?doi=10.1016/j.jcin.2018.05.052&domain=pdf

ABBR EV I A T I ON S

AND ACRONYMS

AVC = abrupt vessel closure

CABG = coronary artery bypass

grafting

CTO = chronic total occlusion

GP = glycoprotein

IVUS = intravascular ultrasound

LSD = longitudinal stent

deformation

MI = myocardial infarction

PCI = percutaneous coronary

intervention

PTFE = polytetrafluoroethylene

Giannini et al. J A C C : C A R D I O V A S C U L A R I N T E R V E N T I O N S V O L . 1 1 , N O . 1 8 , 2 0 1 8

A Practical Approach to Complications During PCI S E P T E M B E R 2 4 , 2 0 1 8 : 1 7 9 7 – 8 1 0

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with coronary perforation include the use ofatherectomy devices (e.g., excimer laser orrotational atherectomy) (4), cutting balloons,intervention on a chronic total occlusion(CTO) (5), advanced age, female sex, andprevious coronary artery bypass grafting(CABG) (2).

Coronary perforation has traditionallybeen classified into 3 types based on itsseverity (Ellis classification) (6). Grade IIIperforations may cause cardiac tamponade,rapid hemodynamic collapse, myocardialinfarction, and death (1,2,7–12).

Management of coronary perforation de-pends on its severity (i.e., the extent of

contrast medium extravasation observed on coronaryangiography) and associated hemodynamic compro-mise, and it is based on the emergent requirement tostop coronary extravasation and ensure hemody-namic stability in the shortest possible time. Figure 1illustrates the potential approaches to coronaryperforation during PCI and highlights the differentmanagement strategies that should be consideredaccording to the perforation site.

The sudden onset of acute and sharp chest painduring balloon inflation or stent deployment shouldalways raise the suspicion of coronary perforationand, in these cases, balloons should remain inthe guiding catheter and at the lesion site untilfurther angiography has been performed to confirm(or exclude) the diagnosis. Once this complicationis confirmed, reversal of anticoagulation could beconsidered and unfractionated heparin may beneutralized with intravenous administration of prot-amine (recommended dose of 1 mg intravenouslyfor each 100 units of unfractionated heparin adminis-tered) to achieve an activated clotting time of <150 s(13). However, this decision should be balancedagainst the potential subsequent risk of acute throm-bosis of a stent that has just been deployed (14).If bivalirudin (as opposed to heparin) has beenadministered, infusion of fresh frozen plasma may bethe only option to partially reverse anticoagulation,although the relatively short half-life of bivalirudinis advantageous here and may facilitate a more rapidhemostasis following cessation of the infusion (15).

Once coronary perforation is confirmed, the sameballoon responsible for the perforation should imme-diately be positioned at the perforation site evenbefore pericardiocentesis as a temporizing measureto achieve immediate hemostasis. The balloon shouldbe inflated at the lowest possible pressure to promotehemostasis as verified by contrast injection at regularintervals: usually inflations to 2 to 4 atm for

approximately 5 to 10 min are sufficient, depending onlocalization and extent of the perforation and onthe tolerability of the patient with occlusion of thecoronary vessel with a specific focus on the develop-ment of myocardial ischemia and hemodynamicinstability. In case of incomplete sealing, the balloonshould be placed in the correct position and inflated athigher pressure. If the perforation involves the leftmain artery, a perfusion balloon (e.g., Ryusei, KanekaMedix, Osaka, Japan) or a covered stent should beconsidered as first-line therapy.

Once the vessel is occluded by the balloon, thepatient’s hemodynamic may normalize; however,aggressive treatment with intravenous fluids, atro-pine, vasopressors, and occasionally mechanicalcirculatory support may be required. The presence ofcoronary perforation should also encourage immedi-ate echocardiography, and when a large pericardialeffusion is associated with tamponade physiology,emergent pericardiocentesis is indicated. Aspiratedblood should be immediately reinfused into a vein topromote hemodynamic stability.

While Ellis grade I perforations can occasionallyresolve without intervention or can generally betreated with reversal of anticoagulation or ballooninflation at/proximal to the target vessel segment,cases of more severe perforation (Ellis grades II to III)are often associated with persistent extravasationdespite prolonged balloon inflations. In these in-stances, other measures to be considered include thelocal delivery of subcutaneous fat, the use ofthrombin, occlusive coils, beads, or the implantationof polytetrafluoroethylene (PTFE) stents. In mostcases, percutaneous measures alone are successful;however, emergency cardiac surgery may be requiredand cardiac surgeons should be notified immediately.Figures 1 and 2 summarize the approach to a patientwith coronary perforation.

The development of PTFE-covered stents consti-tutes a major advance in the treatment of coronaryperforation. These devices have significantly reducedrates of cardiac tamponade, need for emergencycardiac surgery (11,16) and mortality associated withcoronary perforation (12) and are now widely avail-able. Furthermore, current-generation covered stentshave acceptable deliverability in comparison withtheir predecessors. In the presence of a relativelysmall perforation with no significant hemodynamiccompromise, a single guiding catheter strategy isoften sufficient and shortens treatment time. Thistechnique consists of the rapid positioning of thecovered stent immediately after deflation andretrieval of the balloon responsible for the perfora-tion. It is important to note, however, that despite

FIGURE 1 Coronary Perforation

Achieving immediate hemostasis with low-pressure (2 to 4 atm) balloon inflation proximal or at the site of perforation is the first step.

Invasive hemodynamic evaluation and transthoracic echocardiography differentiate stable from unstable patients. In unstable patients,

pericardiocentesis, aggressive resuscitation, and volume support should be initiated to achieve stabilization. The balloon is deflated after

typically 5 to 10 min to evaluate persistence of bleeding. If resolved, angiography should be repeated after 5 to 10 min, confirming definitive

hemostasis. If bleeding persists, further balloon inflation or intravenous protamine should be considered. Further management depends on

the site of perforation. The distal main vessel (1) should be addressed with microsphere or beads, endovascular coils, local thrombin injection,

or subcutaneous fat embolization. The distal side branch (2) can be treated like 1, plus possible delivery of a polytetrafluoroethylene

(PTFE)-covered stent in the main vessel to exclude the perforated branch. The proximal side branch (3), if sufficiently large, can be

considered for direct PTFE-covered stent implantation, or should be alternatively managed like 2. Perforations of the proximal main vessel

(4) can be effectively treated with PTFE-covered stents if not at bifurcation sites. Otherwise, perforations near vessel bifurcations should be

managed with either a PTFE-covered stent or emergency conversion to surgery.

J A C C : C A R D I O V A S C U L A R I N T E R V E N T I O N S V O L . 1 1 , N O . 1 8 , 2 0 1 8 Giannini et al.S E P T E M B E R 2 4 , 2 0 1 8 : 1 7 9 7 – 8 1 0 A Practical Approach to Complications During PCI

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technological improvements in their design, PTFE-covered stents remain bulky when compared withcurrent-generation drug-eluting stents, and theirdelivery into tortuous vessels can be challenging.Therefore, there should be a low threshold to usea separate guide catheter (“ping-pong” guidingcatheter technique) to facilitate PTFE-covered stentdelivery while maintaining hemodynamic stability, asmost guide catheters cannot accommodate both anangioplasty balloon and a PTFE-covered stent graftat the same time (although 8-F guide catheters canaccommodate both a balloon and a 2.5- to 3.0-mm

covered stent). This strategy involves the posi-tioning of a wire from the second guide catheter intothe coronary vessel, with the angioplasty balloonbeing momentarily deflated to allow distal passageof the second guidewire. The PTFE-covered stent isthen quickly advanced across the perforation andis deployed following removal of the angioplastyballoon (17). Side-branch vessels near the perforationsite may be excluded by the PTFE-covered stent,and this may result in periprocedural myocardialinfarction (MI) (15). Intravascular ultrasound (IVUS)should also be used to verify adequate covered-stent

FIGURE 2 CTO Perforation

In the absence of collaterals, the lesion can be managed with microsphere or beads, endovascular coils, local thrombin injection, or

subcutaneous fat embolization. If the affected vessel receives collateral circulation, we should distinguish anterograde versus retrograde

collateral flow. Vessels receiving only anterograde or retrograde collateral flow should be managed with microsphere or beads, endovascular

coils, local thrombin injection, subcutaneous fat embolization, or polytetrafluoroethylene (PTFE)-covered stent deployment of the

donor branches to exclude the perforated vessel. Perforations of vessels receiving both anterograde and retrograde collaterals should be

treated by intervention of both anterograde and retrograde donor vessels to exclude the affected branch. CTO ¼ chronic total occlusion;

IABP ¼ intra-aortic balloon pump.



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expansion as PTFE dual-layer stents deploymentrequires aggressive post-dilatation to >20 atm—thisis particularly important in view of the higher ratesof restenosis associated with the use of these double-layer stents. In some circumstances (more frequentlyin right coronary artery), very deep intubation ofthe guiding catheter should be considered, as thismaneuver gives the double advantage of providingprompt perforation hemostasis and favoring thedelivery of a covered stent without the need of asecond guiding catheter. Figure 3 summarizes theindications for different catheter techniques in themanagement of coronary perforation.

Another increasingly common cause of perfora-tion is the inadvertent distal migration of guide-wires (most commonly hydrophilic wires), resultingin tip-related perforation. Many of these perfora-tions are small and self-limiting and can be managedwith prolonged balloon occlusion proximally to thesite of injury. However, when extravasation persistsdespite these measures, definitive sealing of theperforation site can be achieved with the delivery ofsubcutaneous fat, the use of thrombin, occlusivecoils, or beads (18–24). These items can be selec-tively injected into the distal target with the aid of amicrocatheter, accepting a likely resultant localized

FIGURE 3 Catheter Techniques Useful for Covered Stent Delivery in Coronary Perforation Management

The single guiding catheter strategy consists of the rapid positioning of the covered stent immediately after deflation and retrieval of the

balloon responsible for the perforation. It may be used in small perforations with no significant hemodynamic compromise. The second guide

catheter strategy (“ping-pong” guiding catheter technique) consists of advancing the polytetrafluoroethylene stent from a second guide

catheter across the perforation while the angioplasty balloon is deflated and removed through the first catheter. This is recommended in

perforations with significant hemodynamic compromise and when vessels are tortuous. Very deep intubation of the guiding catheter should

be considered, as this technique gives perforation hemostasis and favors the delivery of a covered stent. RCA ¼ right coronary artery.


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MI with associated biomarker rise. If these in-terventions are unsuccessful, the vessel can beexcluded with a covered stent placed across itsorigin toward another vessel. Cardiac surgery maybe considered if the previously mentioned measuresare unsuccessful and if the patient remains hemo-dynamically compromised.

Coronary artery perforation is more common in CTOinterventions either related to stiff and hydrophilicguidewires or in the context of subintimal dissections(5,24). In the absence of collaterals, the lesion canbe managed with microsphere/beads, endovascularcoils, local thrombin injection, or subcutaneousfat embolization. If the affected vessel receivescollateral circulation, we should distinguish antero-grade versus retrograde collateral flow (Figure 2).Vessels receiving only anterograde or retrogradecollateral flow should be managed with microsphereor beads, endovascular coils, local thrombin injection,subcutaneous fat embolization, or PTFE-covered

stent deployment of the donor branches to excludethe perforated vessel. Perforations of vessels receivingboth anterograde and retrograde collaterals shouldbe treated by intervention on both anterograde- andretrograde-donor vessels to exclude the affectedbranch. In general, the use of intravascular imagingand avoidance of stent oversizing when in the sub-intimal space are important to reduce the risk ofperforation or vessel rupture. While coronary perfo-ration can occur during CTO procedures, we need toemphasize that current CTO recanalization encom-passes a number of very specific complications thatare outside the frames of this work.

Finally, it is worth stressing the importance ofclose patient monitoring following transfer from thecatheterization laboratory, by means of careful he-modynamic evaluations and serial transthoracicechocardiography, to ensure early identification offurther leakage and development of pericardialeffusion/tamponade (23).

FIGURE 4 Abrupt Vessel Closure

Patient stability must be considered first: unstable patients must receive hemodynamic support and ischemia relief with vasopressors, ino-

tropes, intra-aortic balloon pump placement, and left ventricular assist device. Dissections require stent deployment. Subintimal recanali-

zation can be considered if the true lumen cannot be reached. Intracoronary (IC) thrombi are treated with local glycoprotein (GP) IIb/IIIa

antagonists. IC imaging should be considered. If unresponsive, a stent placement should be evaluated. No reflow should be treated with a

“flush cocktail” of adenosine, nitroprusside, nicardipine, or verapamil, with or without abciximab, selectively delivered distally to the oc-

clusion. Air injection demands immediate aspiration or air bubble breakdown with guide or balloon with concomitant administration of 100%

oxygen to aid in its absorption. An inotropic drug may be needed. Vasospasm should be addressed with nitroglycerin, “flush cocktails,”

atropine, fluid boluses, or vasopressors. For abrupt vessel closure of an unknown mechanism, distal contrast injection with microcatheter

should differentiate no reflow from focal dissections. IV ¼ intravenous.



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ABRUPT VESSEL CLOSURE

AVC remains the most common major complicationduring PCI, despite a steady decrease of its incidencefrom approximately 3% in the plain old balloon an-gioplasty era to approximately 0.3% with the use ofcontemporary techniques, thanks to the utilization ofstents with improved deliverability and newer, moreefficacious antiplatelet agents. Dissection, intra-coronary thrombus formation, native thrombus (oratheroma) embolization, air injection, and spasm(25–27) are all potential mechanisms of AVC. Chestpain, electrocardiographic changes, hypotension, orarrhythmias can be manifestations of acute ischemiaassociated with AVC.

The immediate priority in AVC management is toensure the intraluminal position of the coronaryguidewire and, if in doubt, an over-the-wire ballooncatheter or microcatheter should be advanced distalinto the target vessel to allow minimal contrast mediainjection and confirm wire position. Alternatively, toavoid potential dissection propagation due tocontrast injection when the guidewire is located inthe subintimal space, IVUS can be used to confirmwire position.

If intraluminal guidewire position is confirmed, themost likely mechanism underlying AVC is dissectionor intraluminal thrombus. In these cases, a series ofbrief balloon inflations may be able to restore ante-grade flow and reveal the presence of thrombus or

FIGURE 5 Stent Loss

Stent loss requires distinction between on- or off-wire losses. The former should be addressed by nominal inflation of a balloon inside the

stent or by inserting a microcatheter distally to aid stent retrieval. If the lost stent is not on wire, either GuideLiner, intertwined wires, or

gooseneck snares should be considered to retrieve the device. Stent crushing or deployment of a second stent alongside should be considered

if other measures fail. CABG ¼ coronary artery bypass grafting; MI ¼ myocardial infarction.


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dissection. In the latter case, this is typically followedby stenting of the dissection with or withoutthrombus aspiration. Occasionally, the balloon maynot advance or could “watermelon” back more prox-imally, indicating partial subintimal guidewire pas-sage. Here, it is advisable not to attempt subintimalrevascularization while risking extensive dissectionor perforation, particularly in emergency PCI.Instead, the guidewire should be left in place and analternative passage with a second guidewire shouldbe sought. If this proves unsuccessful, an attempt tore-enter the true lumen using CTO techniques mightthen become necessary as a bailout strategy to restoreepicardial blood flow.

If initial contrast agent injection reveals guidewireposition within a false lumen, careful exploration ofthe occluded segment using a second guidewire must

be performed. In these cases, the choice of anappropriate guidewire is important and will largelydepend on the operator’s preference and experience.

Control of anticoagulation is of paramount impor-tance during PCI and particularly when AVC due tointracoronary thrombus formation is suspected.Activated clotting time should be measured at in-tervals of 30 min to ensure appropriate heparin levelsand identify the potential risk of heparin resistance,which could represent the underlying mechanism ofAVC (28). In these circumstances, administration ofglycoprotein (GP) IIb/IIIa antagonists or directthrombin inhibitors such as bivalirudin may beconsidered (28). When AVC is caused by thrombusformation, both intracoronary and intravenousadministration of GP IIb/IIIa antagonists can behelpful.

FIGURE 6 Longitudinal Stent Deformation Induced by Guide Catheter Deep Insertion

(A) Baseline coronary angiogram (CAG) (arrowhead indicates the target lesion with in-stent restenosis). (B) Pre-dilatation with 3.0-mm AngioSculpt (Spectranetics,

Colorado Springs, Colorado). Magnification of (C) baseline CAG and (C’) plane fluoroscopy. (C’) Open arrowheads indicate the left main trunk (LMT) ostium and green

dashed lines indicate previous stent in the LMT. Magnification of (D) CAG and (D’) plane fluoroscopy after pre-dilatation with AngioSculpt. (D’) Open arrowheads

indicate the LMT ostium and yellow dashed lines indicate previous stent in the LMT with longitudinal deformation. (a to c) Intravascular ultrasound (IVUS) findings

after the stent longitudinal deformation (each location of a to c is shown in Figure 2D). (c) Yellow arrowheads indicate deformed stent struts. LAD ¼ left anterior

descending artery; LCx ¼ left circumflex artery; prox. ¼ proximal; RCA ¼ right coronary artery.



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If there is persistence of AVC, intravascular imag-ing should be considered to define the underlyingpathology. Additionally, in the presence of distalcoronary embolization, thrombus aspiration orcompression against the coronary artery wall mightprove successful.

When AVC is caused by inadvertent air injection,immediate aspiration is crucial. This can be combinedwith administration of inotropic agents and imple-mentation of left ventricular support in the presenceof hemodynamic compromise. A different strategyconsists of air bubble breakdown with the aid of a

guidewire or a balloon. Concomitantly, 100% oxygenshould be provided to the patient to facilitate theabsorption of the embolized air.

Guide catheter dissection of a coronary ostium or asegment proximal to the target lesion may cause poorinflow and may be easily overlooked. Dampening orventricularization of the pressure tracings, electro-cardiography changes, or severe ischemic pain shouldalways steer the operator’s attention to exclude anostial guide catheter dissection. In these situations,contrast injection should be avoided or at leastminimized, and the operator should proceed to

FIGURE 7 Complications Associated With Use of Rotational Atherectomy

Rotational atherectomy should always be used with great care, to prevent most common complications: careful case selection is recom-

mended to avoid excessive tortuosity or calcifications; choice of the most appropriate burr size; short ablation runs (<15 s); low burr speeds

and a gentle pecking motion. The 3 main complications include: 1) slow flow or no reflow requiring blood pressure (BP) optimization and local

injection of “flush cocktail”; 2) coronary dissections and perforations, which should be addressed by stopping ablation and treatment like

complications of standard percutaneous coronary interventions (PCIs) (see Figures 1 and 2); and 3) burr entrapment management with

manual pullback with or without Dynaglide (Boston Scientific, Marlborough, Massachusetts) rotation is advised. Distal balloon inflation,

partial Rotablator (Boston Scientific) disassembly, and intravascular snares aid pullback, and emergency surgery should be considered if

previous options fail. PTFE ¼ polytetrafluoroethylene.


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immediate ostial stenting to avoid further distalpropagation of the dissection. Intravascular imagingwith IVUS in this instance may be helpful to confirmthe diagnosis guiding intervention. Figure 4 summa-rizes the management of AVC.

As previously mentioned, hemodynamic stabiliza-tion and ischemia relief are important aspects in AVCmanagement, and can be achieved with a combina-tion of vasopressors, inotropes, intra-aortic balloonpump or ventricular assist devices, depending on theseverity of the hemodynamic compromise. In cases ofpersistent AVC, depending on the location of the oc-clusion, the patient’s clinical conditions, and theassessment of risks and benefits, emergency CABGmay be considered.

It is also important to highlight that an extremevagal reaction or sustained vasospasm may also causeAVC, and in such cases, antegrade coronary bloodflow can be restored by atropine, intravenous fluidboluses, and administration of vasopressors (vagalreaction) or vasodilators (vasospasm).

Another important complication potentially lead-ing to AVC is the coronary no-reflow phenomenon,which consists of the failure to reperfuse myocardiumafter the opening of a previously occluded or

stenosed epicardial coronary artery (24). It is ofparamount importance to immediately differentiateAVC caused by dissection from no reflow becauseplacement of a stent in a vessel with no reflow mayexacerbate the problem. The cause is likely multi-factorial due to a combination of endothelial damage,platelet and fibrin embolization, vasospasm, andextracellular or intracellular tissue edema, ultimatelyleading to neutrophil plugs and platelet infiltration ofmyocardial tissue, microcirculation injury, and in theend, AVC. Coronary no reflow can typically occurduring primary PCI and complex lesion interventioninvolving treatment of venous grafts or rotationalatherectomy, although it has also been described inthe context of non–ST-segment elevation MI or elec-tive PCI (29,30). The no-reflow phenomenon can beprevented or treated with diligent adjunctive phar-macological and mechanical precautions, includingthe use of distal embolic protection devices (particu-larly during degenerated saphenous vein graft an-gioplasty); very selective and distal intracoronary orintravenous medications such as adenosine (31,32),nicorandil (33), nitroprusside, nicardipine, verapamil(34,35), and epinephrine (36,37); and utilizing amicrocatheter or a dual lumen catheter. In our

FIGURE 8 Burr Entrapment

Rotational atherectomy burr entrapment should be prevented by adopting short ablation runs (<15 s) and a gentle pecking motion. Careful

case selection is recommended in avoiding lesions that have excessive tortuosity or calcification. Manual pullback with or without Dynaglide

(Boston Scientific, Marlborough, Massachusetts) rotation is advised; distal balloon inflation, partial Rotablator (Boston Scientific) disassembly,

and intravascular snares can also aid retrieval. Emergency surgery should be considered if these options fail.



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experience abciximab has a limited role to treat noreflow unless a clear thrombus is the cause. Whenthrombus embolization is the main cause, aspirationthrombectomy may be considered, although datarelating to short- and long-term benefits of thisapproach are uncertain (38–41).

DEVICE EMBOLIZATION

Device embolization is a rare PCI complication, and isthe result of the “loss” of a device (e.g., stent, guide-wire, or catheter fragments; misplaced intravascularcoils in the coronary arteries) within the coronaryvasculature. Stents are the most commonly embolizeddevices, with an incidence of approximately 0.32%(42–47). Dislodgement of a stentmay result in systemicor intracoronary embolization. While the former maycause cerebrovascular events, the latter is associatedwith a high risk of coronary thrombosis and subse-quent MI. Extreme tortuosity, angulation, and calcifi-cation increase the risk of stent embolization bydislodgement of the stent from the delivery balloon.Generally, when unexpected difficulties in advancinga stent are encountered, the stent should be gentlyretracted back into the guide catheter (at an early stagebefore stent deformation), removed, and the lesionpredilated (if direct stenting was previously attemp-ted) or further predilated (if lesion preparation hasalready been performed). Stents may also be “lost” ifthe distal tip engages the lesion and remainsembedded when the balloon is retracted for reposi-tioning. Occasionally, stents may be caught by theedge of the guide, with subsequent dislodgment fromthe balloon platform on withdrawal.

Various interventional techniques can be success-fully utilized to retrieve trapped devices, includinggooseneck snares, the use of additional guidewires,and guiding extension catheters (48). Additionally, inthe case of stent loss, if the stent remains on the wire,it is often possible to advance a small balloon beyondthe stent, inflate it, and retrieve the stent by “drag-ging” the balloon back. Another option is to pass asecond wire alongside the embolized stent through astent strut, twist the wires together, and retract thestent. If attempts for retrieval are unsuccessful, itmay be necessary to consider stent crushing to thearterial wall with balloon inflation or deployment ofan additional stent alongside the embolized one,although this is associated with an elevated risk ofperiprocedural MI, death, and referral for CABG (48).In large coronary arteries and difficult access sites,surgical removal should be considered, as it maypotentially represent a less hazardous approach.Figure 5 illustrates techniques that can be employedto manage device loss.

When the embolized item is a small guidewire, theoperator may consider leaving the wire in the coro-nary artery because, to our knowledge, there are noreports describing vessel occlusion caused by aretained guidewire segment (49). However, wireunraveling should be excluded (e.g., by IVUS) beforeleaving the wire in place, as an unraveled guidewiremay form a nidus for thrombus formation. Addi-tionally, in certain instances depending on the posi-tion of the retained fragment, the operator mayconsider stenting the segment to prevent late distalmigration, which could lead to perforation andtamponade.

FIGURE 9 Rotational Atherectomy Burr Entrapment in the Lesion With Excessive Stent Underexpansion

(A, B) Coronary angiogram (cranial and caudal: open arrowheads indicate lesion with severe in-stent restenosis; red arrowheads indicate stent

underexpansion in a severe calcified lesion). (C) Rotational atherectomy burr entrapped (burr size 2.0 mm). (D) Unsuccessful wire crossing

beside the stuck burr. (E) Unsuccessful small balloon inflation on the guide wire crossing to the adjacent septal branch. (F) After surgical

retrieval of the burr entrapped and patch-closure with saphenous vein graft. (G) Left internal mammary artery and left anterior descending

artery distal bypass grafting.


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LONGITUDINAL STENT DEFORMATION

New-generation cobalt-chromium or platinum-chromium stents with thinner struts, albeit withsimilar radial strength and radiopacity (50), arecharacterized by better trackability, pushability,and deliverability. These features allow successfulnavigation in complex lesions (51). However, thereduction of the number of fixed links betweencells and the alteration of their geometry partlysacrifice their longitudinal strength, leading to anincreased risk of longitudinal stent deformation(LSD) (51), defined as distortion or shortening of astent along its longitudinal axis (52). Lesion calci-fication, vessel tortuosity, lesion length $28 mm,ostial disease, and bifurcation disease represent themost common adverse angiographic features for LSDoccurrence; moreover, the use of a GuideLiner,(Vascular Solutions Inc., Minneapolis, Minnesota)balloon post-dilatation, and the number of deployed

stents have all been identified as independent pre-dictors of LSD (53).

LSD can be associated with stent strut protrusioninto the lumen and extensive strut malapposition,which can then result in flow disruption andincreased risk of future stent thrombosis.

Operators should exercise extreme care during PCIfor ostial lesions involving deep intubation withguiding catheters or extension systems throughalready stented segments. Moreover, caution is alsoadvised following deliberate underexpansion of theproximal portion of a very-long stent in a taperedvessel (52). In addition, longitudinal deformation of adrug-eluting stent may result in uneven drug delivery,thereby increasing the risk of in-stent restenosis (54).

When LSD is suspected, radiographic assessmentof the stented segment, preferably with StentBoost(Philips, Andover, Massachusetts) or an equivalentimage-enhancement program, should be carried out.In the presence of LSD, prompt treatment is required

CENTRAL ILLUSTRATION Epidemiology of Mechanical Complications During PercutaneousCoronary Intervention

Giannini, F. et al. J Am Coll Cardiol Intv. 2018;11(18):1797–810.

Epidemiology of mechanical complications during percutaneous coronary intervention and incidence of major outcomes.



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to correct it and prevent stent thrombosis: afterconfirming appropriate wire positioning, a smallcompliant balloon should be used in the firstinstance, followed by a high-pressure noncompliantballoon aiming to ensure adequate expansion of thedeformed stent struts and their apposition to thecoronary arterial wall at the lesion site. If an insuffi-cient angiographic and IVUS result is obtained, im-plantation of a second stent may be necessary.

The use of IVUS or optical coherence tomographyis strongly encouraged, although it is advisable to

proceed to intracoronary imaging once LSD hasbeen treated to avoid further potential deformation.Figure 6 provides an illustrative case example of LSD.

ROTATIONAL ATHERECTOMY

BURR ENTRAPMENT

Serious complications may be encountered with theuse of rotational atherectomy including no reflow,coronary spasm, distal embolization, coronarydissection or perforation, guidewire (55) or drive shaft


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(56) fracture, and burr entrapment (Figure 7). Thelatter occurs rarely, with a reported incidence of 0.4%(57–61). Entrapment consists of burr embedmentthrough a severe stenosis, preventing both furtherburr advancement and retrieval (especially in thepresence of tortuosity or concomitant coronaryspasm). Burr entrapment can be avoided by a gentlepecking motion and short rotablation runs (<15 s).

When entrapment occurs, the most practicalmethod to retrieve the burr is pulling the rotationalsystem back manually. In some cases, the stuck burrcan be withdrawal successfully by manual tractionwith on-Dynaglide (Boston Scientific, Marlborough,Massachusetts) or off-Dynaglide rotation. Excessivelyaggressive retrieval maneuvers may lead to vesselperforation or burr shaft fracture. If simple manualtraction fails, it may be necessary to obtain a separatevascular access. A second guiding catheter can beused to allow advancement of a guide wire beyondthe entrapped burr. Subsequent balloon dilation ofthe lesion along the entrapped burr should facilitateits retrieval (62–64) (Figure 8).

Another potential method of dealing with burrentrapment consists of the partial Rotablator (BostonScientific) disassembly and the use of a percutaneoussnare (65): after disassembling the Rotablator appa-ratus to expose the burr shaft, a percutaneous snare is

advanced just proximal to the burr to provide directtraction on the burr during its withdrawal. An addi-tional alternative strategy involves the use of aGuideLiner catheter (66). When all percutaneousmeasures have failed, emergency cardiac surgery isindicated. Figure 9 summarizes a case example.

CONCLUSIONS

New devices with a superior safety margin, pharma-cological improvements, and hemodynamic supportsystems have all reduced the incidence of PCIprocedure–related complications.

Despite these advances, periprocedural complica-tions still occur and can, in some cases, lead to severehemodynamic compromise or even death (1,2,15–17,25–27,42–49,57–61,67,68) (Central Illustration). Anin-depth knowledge of potential complications and astructured approach to their management is essentialto the interventional cardiologist to ensure preventionand optimize clinical outcomes when complicationsoccur.

ADDRESS FOR CORRESPONDENCE: Dr. FrancescoGiannini, Interventional Cardiology Unit, SanRaffaele Scientific Institute, Via Olgettina, 6020132Milan, Italy. E-mail: [email protected].

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KEY WORDS abrupt vessel closure,coronary perforation, device embolization,longitudinal stent deformation,percutaneous coronary intervention,procedural complications, rotationalatherectomy burr entrapment































































































































































































a practical approach to the management of …...pci = percutaneous coronary intervention ptfe =...

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