ADVERTISEMENT
Case Report
The Diagnostic Importance of Angiographic Visualization of the Distal Vessel in Elucidating the Mechanism of Abrupt Vessel Closu
May 2003
Acute vessel closure is a serious event, complicating 0.5–9.3% of percutaneous coronary interventions (PCI), and is associated with major clinical adverse events including emergency coronary bypass surgery, acute myocardial infarction and death.1–4 Although coronary dissection, thrombosis and spasm are frequently observed, the pathogenesis remained uncertain in up to 50% of cases.2,3,5–9 Accordingly, a specific therapy may not be adequately provided in a timely appropriate manner. In this report, we describe 3 cases of abrupt coronary vessel closure in which conventional interventional approach did not succeed and the mechanism was elucidated by angiographic visualization of the vessel distal to the occlusion site.
Case Report. Patient #1. A 50-year-old male with a history of smoking, type II diabetes mellitus and dyslipidemia was admitted to the hospital with ST elevation anterior wall myocardial infarction (AMI). Intravenous streptokinase (1,500,000 units) was administered with clinical and electrocardiographic signs of reperfusion. A few hours later, the patient experienced recurrence of symptoms and re-ST elevation was noted. The patient underwent urgent coronary angiography demonstrating severe stenosis (99%) of the mid portion of the left anterior descending (LAD) artery with TIMI II flow (Figure 1A). Upon crossing the lesion with a 0.014" Galeo Floppy guidewire (Biotronick®), a complete vessel occlusion occurred, resulting in worsening chest pain, ST elevation and hypotension (Figure 1B). An intravenous bolus of abciximab was administered and dilatation with a 3.0 x 20 mm Worldpass® balloon catheter (Cordis Corporation, Miami, Florida) was performed, followed by deployment of a 3.0 x 15 mm Biodyvisio® stent (Biocompatibles Technology) at the occlusion site without improvement in coronary flow. Subsequently, a Ranger® over the wire balloon catheter (Boston Scientific/Scimed, Inc., Maple Grove, Minnesota) was introduced distal to the occlusion site and contrast was injected, demonstrating widespread distal embolization involving the LAD, diagonal and septal branches without any anatomical obstruction at the abrupt closure site (Figure 1C). Consequently, an approach directed to resolve the distal embolization was undertaken; this included balloon dilatation of the occluded distal portion of the LAD together with intracoronary injection of 20 mg of recombinant tissue plasminogen activator (rt-PA) with rapid restoration of the coronary flow, improvement in symptoms and hemodynamic parameters. The rest of the hospitalization course was uneventful and the patient was discharged a few days later in good condition.
Patient #2. A 68-year-old male with a history of coronary artery bypass surgery at the age of 58, type II diabetes mellitus, dyslipidemia, obesity and bilateral carotid stenosis was hospitalized with rest angina. Electrocardiogram revealed ST-segment depression in leads V4 and V5. Urgent coronary angiography demonstrated severe stenosis of a degenerated saphenous vein graft (SVG) to the obtuse marginal (OM) branch (Figure 2A). PCI was initiated and the patient received an intravenous bolus of heparin as well as an intravenous bolus followed by infusion of eptifibatide (Integrilin). At that time, distal protection devices were not available in our hospital and after crossing the lesion with a 0.014" Choice PT guidewire (Boston Scientific/Scimed, Inc.), balloon predilatation was performed using a 3.0 x 20 mm Worldpass balloon catheter and a 5 x 23 mm Velocity® stent (Cordis Corporation) was deployed. Post-deployment angiogram revealed complete occlusion of the graft at the site of the lesion (Figure 2B). Multiple balloon dilatations were performed distal to the occlusion site without improvement in flow. An over the wire Ranger balloon catheter was introduced distal to the occlusion and 5 cc of contrast medium was injected. The dye completely filled the graft, demonstrating the absence of any flow-limiting stenosis and the presence of the no reflow phenomenon as the sole cause of the abrupt occlusion (Figure 2C). Intragraft urokinase (300,000 units) and multiple boluses of adenosine were administered without significant improvement in flow. Post-procedural course was significant for progressive deterioration and acute, severe mitral regurgitation was diagnosed. The patient underwent urgent mitral valve replacement, but did not recover.
Patient #3. A 59-year-old female was admitted to the hospital with a week of worsening of her angina. She had a history of hypothyroidism, dyslipidemia, hypertension and type II diabetes mellitus. Upon her admission, lateral wall ischemia was diagnosed and the patient underwent urgent coronary angiography revealing significant stenosis of the mid LAD and the first diagonal branch (Figure 3A). Direct stent implantation of a 3 x 11 mm Biodyvisio stent was successfully performed to the LAD lesion. The diagonal lesion was subsequently treated with a 2.5 x 15 mm cutting balloon (IVT EUROPE®) inflated at 10 atmospheres. Dissection was observed at the lesion site and a 2.5 x 10 mm Biodyvisio stent was successfully deployed. Following stent deployment, an abrupt occlusion of the vessel was observed at the stented site (Figure 3B). An over the wire balloon was introduced distal to the complete occlusion and contrast medium was injected through the balloon catheter lumen, filling the artery both antegradely and retrogradely up to the occluded stented site, where residual dissection was observed (Figure 3C). Accordingly, the abrupt closure was attributed to incomplete covering of the previous dissection and an additional 2.5 x 19 mm Biodyvisio stent was implanted with complete restoration of coronary flow (Figure 3D). The procedure was successfully completed and the patient was discharged in good condition 2 days later.
Discussion. The current case series demonstrates the potential value of distal vessel angiographic visualization during abrupt vessel closure. This approach may allow rapid exploration of the underlying mechanism and tailoring of a specific therapeutic approach.
Abrupt vessel closure occurs in 1.8–9.3% of patients after balloon angioplasty and in 0.5–1% after stenting. Coronary flow can be restored in 35–51% of the cases using repeat balloon angioplasty and in more than 90% with bailout stenting.2,4,5 Nevertheless, severe clinical consequences are frequently observed including myocardial infarction (40%), death (4%) and a frequent need for emergency coronary bypass surgery, usually associated with increased peri-operative mortality rate (1.4–6.5%).2
Elucidating the underlying mechanism associated with abrupt vessel closure is paramount for the selection of the appropriate therapy. Coronary dissection with mural hematoma compressing the true lumen of the vessel, coronary thrombosis and spasm are the classic mechanisms of abrupt occlusion.5,7–9 Based on the suspected underlying mechanism, vasodilators, antiplatelet or thrombolytic drugs, perfusion balloons and stents, solely or in combination, are frequently used.2,5,10–13
In the current report, the injection of contrast medium through an over the wire balloon catheter distal to the abrupt vessel occlusion site enabled us to quickly establish the underlying mechanism of abrupt vessel closure. Interestingly, in 2 out of the 3 cases, there was no anatomical obstruction at the PCI lesion site. Multivessel native coronary embolism and degenerative graft-related microembolism associated with no reflow were found to be the ultimate causes. It is conceivable, therefore, that in these 2 cases the impression of abrupt total occlusion was due to the presence of a static blood column filling the vascular lumen, preventing any downstream flow. This phenomenon may reflect the impact of a large embolic mass that could be potentially prevented using a distal protection device. The current unexpected observation supports the idea that cases diagnosed as acute coronary occlusions, particularly when the mechanism is unclear or the treatment is unsuccessful, may merely be an unusual presentation of distal vessel or microcirculation occlusion rather than true epicardial, target lesion site occlusion.
The third case was an abrupt occlusion secondary to coronary dissection. In this case, the injection of contrast through an over the wire balloon catheter demonstrated occlusion at the PCI target lesion site related to residual dissection not fully covered by the initially implanted stent. In addition, the distal end of the occluded segment could be established precisely, allowing site-specific second stent implantation with prompt restoration of flow.
Injection of dye or drugs through catheters placed distal to occluded vascular sites is not new and has been applied previously during the treatment of chronic total occlusion,14,15 in cases of large burden of thrombus (lytic agents) or in the presence of distal embolization phenomena.14–17 It is important to recognize, however, that injection via over the wire balloon carries potential complications, such as an injury to the arterial wall by the unprotected distal tip and extension of a false lumen. Use of specifically designed over the wire catheters may minimize such potential trauma.
In summary, this is the first report describing the use of contrast medium injection through a balloon catheter distal to the occlusion site to explore potential mechanism of abrupt closure during coronary angioplasty and tailoring a direct therapeutic approach.
1. Abdelmeguid AE, et al. Long-term outcome of transient, uncomplicated in-laboratory coronary artery closure. Circulation 1995;91:2733–2741.
2. Danchin N, et al. Changes in patient treatment after abrupt closure complicating percutaneous transluminal coronary angioplasty: A historic perspective. Am Heart J, 1995;130:1158–1163.
3. Lincoff AM, et al. Abrupt vessel closure complicating coronary angioplasty: Clinical, angiographic and therapeutic profile. J Am Coll Cardiol 1992;19:926–935.
4. Bittl JA, Ahmed WH. Relation between abrupt vessel closure and the anticoagulant response to heparin or bivalirudin during coronary angioplasty. Am J Cardiol 1998:82:50P–56P.
5. Bergelson BA, Fishman RF, Tommaso CL. Abrupt vessel closure: Changing importance, management and consequences. Am Heart J 1997;134:362–381.
6. Haude M., et al. Immediate stent implantation versus conventional techniques for the treatment of abrupt vessel closure or symptomatic dissections after coronary balloon angioplasty. Am Heart J 2000;140:820.
7. Bonnet JL, et al. Acute complications of coronary angioplasty: Prevention and management. Arch Mal Coeur Vaiss 1999;92(11 Suppl):1571–1578.
8. Basso C, et al. The early and late complications after percutaneous balloon coronary angioplasty. G Ital Cardiol 1993;23:1079–1090.
9. Farb A, Lindsay J Jr., Virmani R. Pathology of bailout coronary stenting in human beings. Am Heart J 1999;137:621–631.
10. Clinical experience with intracoronary tissue plasminogen activator: Results of a multicenter registry. Intracoronary t-PA Registry Investigators. Cathet Cardiovasc Diagn, 1995;34:196–201.
11. Crouch MA, Nappi JM. Adjunctive intracoronary thrombolysis in complicated coronary angioplasty. Ann Pharmacother 1997;31:1244–1246.
12. George BS, et al. Multicenter investigation of coronary stenting to treat acute or threatened closure after percutaneous transluminal coronary angioplasty: Clinical and angiographic outcomes. J Am Coll Cardiol 1993;22:135–143.
13. Haase KK, et al. Frequency and efficacy of glycoprotein IIb/IIIa therapy for treatment of threatened or acute vessel closure in 1,332 patients undergoing percutaneous transluminal coronary angioplasty. Am Heart J 1999;137:234–240.
14. McKay RG, et al. Treatment of intracoronary thrombus with local urokinase infusion using a new, site-specific drug delivery system: The Dispatch catheter. Cathet Cardiovasc Diagn 1994;33:181–188.
15. Barsness GW, et al. Reduced thrombus burden with abciximab delivered locally before percutaneous intervention in saphenous vein grafts. Am Heart J 2000;139:824–829.
16. Chaloupka JC, Mangla S, Huddle DC. Use of mechanical thrombolysis via microballoon percutaneous transluminal angioplasty for the treatment of acute dural sinus thrombosis: Case presentation and technical report. Neurosurgery 1999;45:650–656; discussion 656–657.
17. Gurbel PA, et al. Lesion-directed administration of alteplase with intracoronary heparin in patients with unstable angina and coronary thrombus undergoing angioplasty. Cathet Cardiovasc Diagn 1996;37:382–391.
