“Cavity spilling” perforation during recanalisation of the right coronary artery – reocclusion of the recanalised artery as a method of emergency treatment

Introduction

Coronary artery perforation is a rare but very severe complication of percutaneous coronary interventions (PCI). Its frequency ranges from 0.1% to 3.0% [1-4]. Clinical factors predisposing to perforation include older age and female sex [1]. The risk of perforation is mainly related to the presence of a three-vessel disease and B2 or C type atherosclerotic lesions, especially those caused by chronic occlusions and accompanied by calcifications. The risk of perforation is also mediated by the type of devices used to open the artery such as a rotablator or an excimer laser [2, 5]. Perforations are more likely to occur with the use of hydrophilic guidewires, especially those that are stiff and have a high tensile strength [6]. Other causes include the use of too large balloons or stents unadjusted to the vessel size.

We present a case of a perforation during recanalisation of the chronic total occlusion (CTO) of the coronary artery. The reason for perforation was rather typical, but the management, although influenced by the situation, was unconventional and, what is most important, effective.

Case report

Clinical data

A 78-year-old female patient with symptoms of stable angina CCS class II was admitted for an elective recanalisation of the right coronary artery (RCA). The patient had a history of myocardial infarction of the inferior wall (STEMI) in 2011 treated with PCI of the circumflex artery (CX) with bare metal stent implantation. In June 2011 the patient suffered from a non-ST-segment elevation myocardial infarction (NSTEMI). Coronary angiography performed at that time revealed the presence of the following changes: RCA – critical stenosis in the middle segment and occlusion in the distal segment of the vessel (Figure 1), LM – no changes, LAD – parietal changes, CX – ostial occlusion. Due to the presence of symptoms of myocardial infarction an ad hoc successful CX recanalisation with drug-eluting stent implantation was performed (Endeavor Resolute 3.0/30 and Endeavor 2.75/30 – Medtronic).

The patient medical history included previous implantation of a vascular prosthesis for the treatment of Leriche syndrome, previous radiotherapy for the treatment of cervical cancer, and thyroid goitre in the state of euthyroidism. Pharmacotherapy included clopidogrel 1 × 75 mg, aspirin 75 mg, atorvastatin 40 mg, metoprolol succinate 1 × 25 mg and pentoxifylline 2 × 400 mg (Figure 1).

Description of the procedure

Recanalisation of the RCA was attempted via the left radial access. After cannulation of the RCA ostium with a guiding catheter JR4 6 F (Launcher, Medtronic) and administration of 6500 IU of unfractionated heparin the Pilot-50 0.014 guidewire (Abbott) was easily introduced through the occlusion site. This step was followed by predilation with a balloon catheter Mini Trek 2.0/25 (Abbott) to 18 atm, which did not lead to dilation of the lesion. Full dilation of the lesion was obtained using the non-compliant NC Trek 2.5/25 balloon (Abbott) inflated to high pressure (28 atm). Inflations with lower pressures led to balloon modelling on the lesion, which suggested marked “hardness” of the lesion, and were a marker confirming the presence of a long-lasting occlusion (Figure 2). A control contrast injection performed after predilation showed a mild contrast leak (Figure 3). Leakage was stopped with prolonged balloon inflation. A decision was made to implant a drug-eluting stent, Xience V 2.75/23 (Abbott), at 12 atm. Stent implantation led to a marked increase of blood extravasation, suggesting a communication between the RCA and the right ventricle (Figures 4-6). An attempt to stop bleeding with prolonged (5 min) inflation of the stent balloon at the site of the perforation was made. Due to increase of bleeding (Figure 7) it was decided to implant a stent graft. An attempt to introduce it down to the site of the perforation was unsuccessful. Therefore it was decided to reocclude the recanalised artery by stent graft implantation at the site of RCA-right ventricular branch bifurcation. After introduction of an additional guidewire, Whisper MS 0.014 (Abbott), into the right ventricular branch, a direct stent graft implantation was performed (Jostnet GraftMaster 3.0/16, 12 amt – Abbott) (Figure 8), leading to complete cessation of blood extravasation into the right ventricle (Figures 9-10). The time of fluoroscopy was 15.8 min; radiation dose was 1.9 Gy and 210 ml of Imoeron contrast was used (Bracco S.p.A. Patheon Italia S.P.A.).

Despite the described complications the patient remained haemodynamically stable throughout the whole procedure. She did not complain of any pain. Repeated echocardiographic examinations performed after the procedure did not show the presence of pericardial fluid.

Discussion

The currently used classification of perforations was proposed in 1994 by Ellis et al. [1]. It consists of 3 types: type I – extravascular limited crater of contrast without extravasation; type II – pericardial or myocardial blush without extravasation through the perforation; and type III – extravasation into the pericardium or myocardium through frank ( 1 mm) perforation. Additionally there is one more type of perforation (CS – cavity spilling) in which contrast spills directly into the anatomical heart cavities or into the coronary sinus. The situation presented by us should therefore be considered as this type. The described type of perforation should be differentiated from the possible congenital RCA-right ventricle fistula which emerged after transient vessel recanalisation. This may not be clearly determined; nevertheless, therapeutic management in the case of a cavity spilling perforation or a congenital fistula is similar.

Most large and symptomatic perforations drain to the pericardial cavity. Extravasation of blood into this cavity causes a local increase of pressure and as a consequence a slower or faster onset of symptoms of cardiac tamponade. Perforation leading to communication between the coronary artery and the right ventricular cavity does not lead to severe and rapid complications due to high susceptibility of the right ventricle. Despite good short-term prognosis in the case of a large diameter perforation, it produces an arteriovenous fistula with all the haemodynamic and clinical consequences of the right-to-left shunt [7]. These include progression to heart failure, ischaemia caused by a damaged artery, and rare but extremely important clinical risk of infectious endocarditis. Therefore large fistulae caused by perforations unquestionably require treatment.

The anatomical conditions make the management in the present case particularly challenging. A therapeutic option may include surgical suturing or ligation of the artery with subsequent coronary artery bypass grafting [8]. However, it is easier to refer for surgery a patient with 3-vessel disease than a patient with 1-vessel disease (the patient had a history of a successful PCI of the CX with DES implantation) when the risk of cardiac surgery may outweigh the benefits. In that case a possibility of percutaneous intervention should be considered. Percutaneous methods include transcatheter introduction of coils, which is often used for the closure of congenital coronary fistulae [9]. Other methods of perforation closure such as thrombin or polyvinyl alcohol injection or embolisation using an autologous thrombus or geoflam cannot be applied due to a relatively large diameter of the fistula and rapid blood flow between the arterial and venous system and therefore should be reserved for type II and III perforations.

The traditional and commonly used method of perforation treatment consists of implantation of a polytetrafluoroethylene-covered stent graft [10]. The use of stent grafts may be considered for “cavity spilling” perforations only in cases where a guidewire is definitely placed in the true arterial lumen and the origin of the fistula is perpendicular to the arterial lumen. In that case, stent graft implantation leads to closure of the fistula ostium, which causes cessation of blood flow into the cardiac cavity. This was the situation described in that case. However, difficulties of stent graft introduction into the site of perforation excluded the use of that option. Successful solution of the problem consisted of stent graft implantation into the RCA-right ventricular branch bifurcation, which led to cessation of blood flow into the right ventricular cavity. At this point a much more challenging situation when closure of the branch may be a successful aid for the patient should be mentioned. In that case the intramural part of the fistula runs in the continuity of the vessel and therefore stent graft implantation would cause dilation of the perforation and increase of extravasation. Therefore partial localization of the stent graft inside the branch and closure of the vessel above the fistula would help to successfully take control of the situation. Despite a perfect angiographic effect of the stent graft implantation at the end of the procedure, one should remember that these stents are characterized by a higher risk of in-stent thrombosis and require prolonged combined antiplatelet therapy. This type of stent is also characterized by a high restenosis rate and usually leads to occlusion of the side branches. For these reasons, the patient should remain under strict medical control to enable early detection of the described complications.

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