Dual-Catheter Covered Stenting: A Novel Approach to the Treatment of Large Coronary Artery Perforations

Coronary perforation is an infrequent, but well recognized, complication of percutaneous coronary intervention. In 1994, Ellis et al. classified coronary perforations on a scale of 1–3 based on angiographic criteria.1 A subsequent study by Dippel et al. examined in-hospital outcomes of these patients.2 Those patients with large perforations (Class 3, frank streaming of contrast through a >= 1 mm exit hole) had a mortality of 21.4% versus Case Report. In August 2001, a 70-year-old woman with a history of type II diabetes mellitus and hypertension presented with unstable angina and underwent stenting (3.5 mm diameter) of the mid left anterior descending coronary artery (LAD). She returned in December 2001 with typical exertional anginal symptoms associated with dyspnea. The patient underwent cardiac catheterization. The left ventriculogram demonstrated mild anteroapical hypokinesis. The remaining segments were hyperdynamic. The left main coronary artery (LMCA) was normal. The LAD demonstrated a 90% Type I in-stent restenosis involving the proximal half of the LAD stent.3 The first diagonal branch originated from within the stent and did not appear narrowed. The left circumflex coronary artery and right coronary artery were angiographically normal. There were no collaterals noted. A 6 French (Fr) EBU 3.5 guiding catheter (Medtronic AVE, Danvers, Massachusetts) was used to engage the left coronary system. An 0.014´´ x 300 cm Hi-Torque floppy guidewire (Guidant Corporation, Temecula, California) was advanced to the distal LAD. A 3.5 x 15 mm cutting balloon (Interventional Technologies, San Diego, California) was advanced within the stent and inflated to 16 atmospheres for 27 seconds. When the balloon was deflated, arteriography demonstrated a wide-based coronary perforation with both myocardial staining and free flow of contrast into the pericardium. The cutting balloon was reinflated and protamine was administered. After 12.5 minutes, the balloon was deflated and extravasation of the contrast continued to be noted (Figure 1). The cutting balloon was quickly removed and a 3.0 x 20 mm Esprit perfusion balloon (Guidant Corporation) was quickly inserted and inflated to 6 atmospheres for 17.5 minutes. When the balloon was deflated, free extravasation of contrast continued. The balloon was reinflated and left femoral arterial access was achieved with an 8 Fr sheath. An 8 Fr EBU 3.5 guiding catheter was advanced to the left coronary ostium. The 6 Fr guiding catheter was slightly disengaged from the LMCA without moving the balloon. A second high-torque floppy guidewire was advanced through the 8 Fr guide into the distal left anterior descending (LAD) artery. The perfusion balloon was briefly deflated and then reinflated, allowing the second guidewire to advance down the LAD. A 13 mm covered stent (Jomed Inc., Germany) was hand-mounted on a 3.0 x 12 mm Quantum Ranger balloon dilatation catheter (Boston Scientific/SciMed, Inc., Maple Grove, Minnesota) and advanced over the wire in the 8 Fr guiding catheter. When the covered stent was at the tip of the guiding catheter, the perfusion balloon was deflated and withdrawn into the guiding catheter. The covered stent was quickly advanced into position and deployed at 18 atmospheres for 30 seconds (Figure 2). Post dilatation was performed with a 3.25 x 20 mm Quantum Ranger balloon. Repeat arteriography demonstrated a widely patent vascular lumen without evidence of contrast extravasation (Figure 3). The patient remained hemodynamically stable, but did demonstrate a mild pulsus paradoxus. Subsequent right heart catheterization revealed evidence of diastolic equalization. A pigtail catheter was inserted into the pericardium and 350 cc of blood were removed. The patient returned to the catheterization laboratory the follow day. Repeat arteriography was performed, which demonstrated a widely patent stent with excellent distal flow and no evidence of residual perforation. Serial CPKs remained below the upper limit of normal. The pericardial catheter was removed. After 48 hours, the patient was transferred to the floor and discharged 48 hours later. Clinical follow-up 1 month later demonstrated no residual chest pain or dyspnea. Discussion. Coronary artery perforation complicating percutaneous coronary intervention, although infrequent, can be abrupt and occasionally catastrophic. Perforation during balloon angioplasty has been reported in 0.1–0.6% of cases, increasing to 2.0–2.8% with atheroablative techniques. Typically, cutting balloons are oversized by 0.25 mm when treating in-stent restenosis and are inflated up to a maximum of 10 atmospheres. The cutting balloon is noncompliant and does not grow appreciably even at high pressures. The major risk for high-pressure inflations is balloon rupture, which did not occur in this case, and not perforation. In the Global Randomized Trial (GRT), perforations appeared to be associated with oversizing the cutting balloon (balloon:artery ratio > 1.1) which was not present in this case (Cutting Balloon Package Insert). There appear to be no predictive clinical risk factors for perforation, although 1 study did support a significant increased incidence with underlying congestive heart failure.2 Class 1 and 2 perforations were associated with lower incidences of death (0%) and urgent coronary artery bypass graft surgery (0%). There was a 5.3% incidence of tamponade and pericardiocentesis in Class 2 perforations. Class 3 perforations were associated with much higher rates of death (21.4%), urgent CABG (50%), tamponade (42.9%) and pericardiocentesis (50%).2 In Class 3 perforations, the rapid extravasation of blood through a >= 1 mm hole within a nondistended and noncompliant pericardium leads to tamponade with only small amounts of blood in the pericardial space. Pericardiocentesis may be difficult due to the small volume of blood in the pericardium. Echo-guided needle insertion may be useful.4 At the time a Class 3 perforation is first noted, immediate balloon inflation at or proximal to the disruption is mandatory. Protamine should be administered to reverse heparin and platelets infused if abciximab has been given. Platelet transfusions are unlikely to be useful in patients receiving tirofiban or eptifibatide, as these are reversibly bound to the IIb/IIIa receptor. Prolonged balloon inflations of 20–30 minutes should be performed if tolerated, preferably with a perfusion balloon to preserve blood flow. However, exchanging the culprit balloon for a perfusion balloon may allow enough time for tamponade and clinical deterioration to develop. As 6 Fr and smaller guiding systems have become more frequently used, treatment of perforations may be more difficult. The Jomed hand-mounted covered stent will not track well through a 6 Fr guiding catheter, especially one with moderate angulation. Covered stents > 3 mm in diameter will not pass through a 6 Fr guiding catheter. To ameliorate these difficulties, we have devised a dual-catheter covered stent technique whereby the perforation remains sealed for the longest possible time while a covered stent is brought into position using a second guiding catheter with a large inner diameter. We recommend first removing atheroablative devices and replacing with a perfusion balloon. If no atheroablative devices were used, inflate the culprit balloon at, and/or proximal to the perforation. Next, reverse the heparin and abciximab as described above. Access is then achieved from the contralateral femoral artery. A 7 Fr or larger diameter guiding catheter is advanced to the coronary ostium. As the second guide is brought into position, the first guide should be gently moved away from the ostium without disturbing the occluding balloon. A second guidewire is advanced through the second guide beyond the perforation. The occluding balloon should be briefly deflated to allow passage of the wire. The covered stent should be prepped and mounted, then advanced to the end of the second guide. The occluding balloon should be deflated and withdrawn. Quickly, the covered stent should be advanced to cover the perforation, the first guidewire withdrawn, and the covered stent then deployed at high pressure. Repeat angiography should be performed to ensure closure of the perforation. In our patient, this technique resulted in closure of the perforation, an excellent angiographic result with TIMI grade 3 flow, resolution of chest pain and hemodynamic stability throughout the procedure. Given the low frequency with which these perforations occur, a randomized study of different techniques is not likely to occur. However, when a Class 3 perforation is encountered, we recommend the dual-catheter covered stenting technique for the aforementioned reasons.

1. Ellis SG, Ajluni S, Arnold AZ, et al. Increased coronary perforation in the new device era: Incidence, classification, management, and outcome. Circulation 1994;90:2725–2730. 2. Dippel EJ, Kereiakes DJ, Tramuta DA, et al. Coronary perforation during percutaneous coronary intervention in the era of abciximab platelet glycoprotein IIb/IIIa blockade: An algorithm for percutaneous management. Cathet Cardiovasc Intervent 2001;52:279–286. 3. Mehran R, Dangas G, Abizaid AS, et al. Angiographic patterns of in-stent restenosis. Classification and implications for long-term outcome. Circulation 1999;100:1872–1878. 4. Tsang TS, Freeman WK, Barnes ME, et al. Rescue echocardiographically guided pericardiocentesis for cardiac perforation complicating catheter-based procedures. The Mayo Clinic Experience. J Am Coll Cardiol 1998;32:1345–1350.