“Cath Lab Catastrophes: Management and Prevention” “Cath Lab ...

China Interventional Therapeutics (CIT) 2008
March 20 -- 23, 2008
Beijing, China
“Cath Lab Catastrophes:
Management and Prevention”
Fayaz Shawl, M.D., F.A.C.C.
Clinical Professor of Medicine
Director of Interventional Cardiovascular Medicine
George Washington University - Washington, D.C.
Director Interventional Cardiology
Washington Adventist Hospital - Takoma Park, Maryland

Faculty Disclosure
Fayaz Shawl, M.D., F.A.C.C.
Research/Grant Support:
Cordis Corporation

Defensive Angioplasty
Knowledge of clinical and morphologic factors
relating to mortality and complications
Do not overextend your capability
Knowledge of complications relating to different
devices
Plan offensive strategy to handle various anatomic
subsets, plan defensive strategy if failure occurs
Anticipate failure
Review each complication (may prevent the next!)
Record and monitor your results, review at frequent
intervals

THE MORTAL RISK OF
INTERVENTION IS MORE
CLOSELY ASSOCIATED WITH
COMPLEX PATIENTS
THAN WITH
COMPLEX LESIONS

Complications of of Percutaneous Intervention: Elective Stenting
Mortality
20
15
10
5
0
Risk Factors
1. EF < 40
Multivariate Correlates of In-Hospital Mortality
2. Creatinine > 1.5
3. Age > 70
4. Triple Vessel Disease
5. Unstable Angina
0.35 0.16 0.52
4.82
3.57
0 1 2 3 4 5
No. of Risk Factors
17.39
N N = = 283 641 574 311 84 84 23 23
(Number of of vessels dilated & & lesion morphology not significant)

Mayo Clinic Risk Risk Score Variables: Predictors of of
Death, Q Q Wave MI, MI, Emergent or or Urgent CABG, CVA CVA
Clinical Variables
Age
Cardiogenic shock
S. creatinine > 265 µml/l (>3.5 mg/dl) or
history of chronic or end stage renal disease
Urgent or emergent procedure
NYHA > 3 heart failure
Angiographic Variables
Thrombus
Left main disease
Multi-vessel disease
Developed from learning set of 5,463 procedures, January 1996-December 1999.
Validated in 1,781 procedures in 2000. Validated in 3,264 pts in NHLBI Dynamic Registry.
Singh M. et al. JACC 2002;40:387-93
Singh M. et al. JACC 2003;42:722-8

Major Complication Rate (%)
25
20
15
10
5
0
Risk:
Risk Score:
Mayo Clinic Risk Risk Score for for PCI PCI
≤ 2
Very Low
0-5
2-5
Low
6-8
5-10
Moderate
9-11
10-15
High
12-15
JACC 2002;40:387
≥ 25
Very High
>15
Risk Factor:
Age 90-99: 6
Shock: 5
Left main: 5
Age 80-89: 5
Age 70-79: 4
Renal disease: 3
Age 60-69: 3
Non-elective
procedure: 2
MV Disease: 2
NHYA > 3: 2
Thrombus: 2
Age 50-59: 2
Age 40-49: 1

Lower Pre-Procedural Hemoglobin Level is Associated
with Increased Risk of In-Hospital Mortality
26,313 consecutive PCI, 9 hospitals, University of Michigan
Hgb Level
6.6-12.3
12.3-13.5
13.5-14.4
14.4-15.4
15.4-20.1
All PCI Patients
N = 24,554
2.9%*
1.6%
1.1%
0.9%
1.1%
Mortality, In-Hospital
S. Beinart et al. Circ 2002;19:3700
PCI with AMI (

Cath Cath Lab Lab Complications
Prophylactic use of IABP and Integrilin

Cath Cath Lab Lab Complications

Cath Cath Lab Lab Complications
Result

Cath Cath Lab Lab Complications

Cath Cath Lab Lab Complications
Error of Omission - Post IVUS Evaluation

Coronary Dissection Following PCI PCI
Causes
Guide Catheter:
L Amplatz Guide
# 6 Fr. JR4 Guide!!
Balloon/Stent Oversizing
Overexpansion
particularly on angle >
45°
Calcified Vessel
Chronic Total Occlusion

Edge Edge Dissection Following Stenting
Non-flowing limiting. Arc of dissection <
90°
STRUT Trial
Incidence 17%; no in-hospital complications
Hong, et al. - 327 pts
Incidence 20.4%; no in-hospital complications
6-month TLR 23.9 vs 22.3%
SHERIS Trial - 150 pts
Incidence 10.7%; 6-month TLR 25% vs 27%
All tears healed by IVUS

Cath Cath Lab Lab Complications

Cath Cath Lab Lab Complications
Recurrent Chest pain 6 hrs. post-PCI

Dissections Following Elective Coronary Stent
Placement: Acute and and Long-Term Outcomes
No
Dissection
Dissection
A-B
Dissection
C-F
No. 1426 101 52
Pvalue
30 Day: Death (%) 0 0 2 0.11
Q AMI (%) 1 0 4 0.03
Non Q AMI (%) 5 4 13 0.007
9 Month: Death (%) 1 2 2 0.18
Q AMI (%) 1 1 4 0.01
Non Q AMI (%) 5 4 15 0.005
TLR (%) 10 8 19 NS
J. Saucedo et al. Circ 2000;102:1155

Stent Thrombosis
Management
Mechanical opening of stent
Management of thrombus
IIbIIIa inhibitor
Angiojet
X-SIZER (Endicor)
Aspiration Thrombectomy
Identify the Cause
IVUS evaluation
Check medications

Coronary Perforation
Perforation Classification
TYPE I: Extraluminal crater without
extravasation
Type II: Pericardial or myocardial blush
without contrast jet extravasation
Type III: Extravasation through frank (> 1
mm) perforation
Type III (Cavity Spilling): Perforation into
anatomic cavity (e.g. Coronary Sinus)
S.G. Ellis et al. Circ 1994;90:2725-30

Coronary Perforation
Clinical Outcome 62/2900 Procedures
(0.5%)
Death Em-CABG Q-AMI Tamponade
Type N (%) (%) (%) (%)
I 13 0 15 0 8
II 31 0 10 0 13
III CS 2 0 0 0 0
III 16 19 63 15 63
S.G. Ellis et al. Circ 1994;90:2725-30

Cath Cath Lab Lab Complications
Chronic
Total
Occlusion

Coronary Perforations:
Incidence, Predictors and and Outcome
5728 pts; 10,000 lesions; 4/93-11/01 Milan Italy
Incidence 84 pts (1.5%)
POBA 45 (53.6%)
DCA 8 (9.5%)
Rota 3 (3.6%)
Cutting balloon 2 (2.4%)
Guidewire 23 (27.4%)
Other devices 3 (3.6%)
Atheroablative procedure 2.4% vs. 1.3%
Complex lesions 1.9% vs. 0.5%
Higher B/A ratio 1.3 vs. 1.2
G. Stankovic et al. Circ 2002;19:2210

Coronary Perforations:
Incidence, Predictors and and Outcome (cont.)
5728 pts; 10,000 lesions; 4/93-11/01 Milan Italy
Outcomes
In-hospital In-hospital MACE 34.5%
AMI 17.8%
Em-CABG 13.1%
Death 8.3%
G. Stankovic et al. Circ 2002;19:2210

Vessel Perforation: Management
Don’t panic
Prolonged balloon inflation
Reverse heparin
Platelet infusion, FFP
Echocardiogram
Pigtail catheter to pericardium
Covered stent (if deliverable)
Gelfoam or thrombus occlusion of vessel
Surgery rarely required
Follow-up echocardiogram very important

Air Embolus
Often from manifold injections
(contrast or flush)
Prevention
Avoid pressurized flush
Back bleed before injecting
Small amounts are well tolerated
Large amounts cause “Air Lock”
Chest Pain
Bradycardia
Hypotension

Air Lock: Management
Don’t Panic
100% O2
Morphine, Atropine
Neosynephrine 0.1 mg. IV
I/C Epinephrine 1:10,000 dil.
Turn patient
Suction / Flushing
IABP
CPS (for refractory hemodynamic
collapse)

Death
Risks Risks of of PCI PCI
Myocardial infarction
Acute closure
Vascular perforation
Embolus of clot or air or plaque debris
Side branch occlusion
Hematoma and Hemorrhage
Others: SAT
Renal failure

Cerebrovascular Complications
Rare (0.07%), mostly embolic in
origin, careful management of
wires, guide catheter, and flush
Endocarditis patient: LV thrombus -
avoid LV gram
Majority from plaques on aorta
Check ACT - keep > 250 sec.

Myocardial Infarction
Mechanism Dissection, Abrupt closure,
Side branch closure, No
reflow, Thrombosis, Distal
embolism
Recent trials Q-wave at 1 - 2%
Non-Q MI 5 - 10%
CPK/MB 1 - 3x elevation: little
consequences
> 5x elevation: adverse
long term effects

Acute Closure
Abrupt closure: 2 - 9% (TIMI 0-II
Flow)
Threatened closure: Dissection or
Thrombus with TIMI III Flow
Prevention:
Antiplatelets
IIb/IIIa inhibitors
Treat thrombus before stenting

Factors Associated with with Abrupt Abrupt Closure
Clinical: unstable angina, female,
AMI, chronic renal failure
Angiographic: Intraluminal thrombus,
long lesion, > 45 degree
angulation, branch points,
proximal tortuosity, ostial
RCA, SVG, prestenosis >
90%, intimal dissection

Predictors of of Mortality after after Abrupt Abrupt
Closure
% myocardium at risk
LM & MV disease
CHF, UA
Target vessel supplies collaterals
Age > 65
Chronic Renal Failure
Female gender
Diabetes

Stent vs. Conventional Techniques for the Treatment of
Abrupt Vessel Closure or Symptomatic Dissections
100 pts with abrupt vessel closure / symptomatic
dissection
Randomized to Stent (n = 51) vs. Prolonged
dilation/Emergency CABG
In-Hospital
Events
Stent
(n = 51)
Standard
(n=49)
Death 2% 2%
QMI 16% 8%
Emerg CABG 4% 0

Think: dissection, embolus, air,
hypotension as well as microemboli
High risk with SVG, Thrombus, Rota,
Diffuse disease
Prevent: ?IIbIIIa, CA ++ Prevent: ?IIbIIIa, CA antagonists,
++ antagonists,
Adenosine, DPD
Slow Slow or or No No Flow
Flow
Treat: Support B/P with pressors, IABP
Administer: distal Nitroprusside,
Adenosine, CA ++ Administer: distal Nitroprusside,
Adenosine, CA antagonists, Epinephrine
++ antagonists, Epinephrine

Coronary Perforation
PTCA 0.1%, Roto/DCA 0.5 - 2.0%. Stent
0.5%
Wire perforation (3/7000) rare, but may be
slow to be recognized. Often with stiff wire,
hydrophilic wire
If device doesn’t follow, usually benign
Device perforation can be rapidly fatal
May occur hours later
Clinical signs are variable
Treatment: reverse A/C, perfusion balloon,
centesis, covered stents, coils, RH Cath,
serial ECHOs

Perforation Risk Risk
Wire - Vessel Tortuosity (Esp.
Hydrophilic Wire Use)
Ablative Techniques - With Vessel
Tortuosity
Stents - Small Calcified Vessels / High
B/A Ratio
Interaction with IIbIIIa inhibitors
???

Coronary Perforation in in the the Era Era of of Abciximab
36 perforations
6,214 PCI (0.58%)
73.7
Abciximab use
57.1
21.2
Portamine
64.3
15.8
Platelet TX
50
erfusion balloon
26
85.7
5.3
Tamponade
42.9
5.3
Pericardiocentesis
E Dippel et al., CCI 2001
Perforation class by Ellis et al.
50
0
Urgent CABG
Class II
Class III
50
Death
21.4
0

Coronary Perforation in in the the Era Era of of Abciximab
N = 6,999 consecutive PCI from 1994 thru 1996
Overall tamponade incidence 0.2% (15 pts)
Perforation Causes:
Target Lesion Site (n=5)
Tip of Guidewire (n=3)
Temporary Pacemaker Wire (n=7)
0.3
2.3
3.2
10.8
PTC Stent DC/TEC ROTA
Incidence by device
Von Sohsten et al, Am Heart J 2000
# per 1000 pts

Subacute Stent Thrombosis
Increased risk with small vessels, multiple
stents, uncovered dissection, low EF
DES: multiple stents, long stents, small
vessels, risk even higher - up to 1 year
after stopping antiplatelets
Risk for Q-wave MI: 60%
Mortality: up to 25%

Allergic Reactions
Local anesthetic (rare), contrast, protamine
Anaphalactoid (no IgE)
Increased risk with atopic disorder, seafood (?),
prior contrast reaction
Prevent: Prednisone (13 hrs+), H1 and H2
blockers, Premedications
Treat: One ml of Epi 1:10:000 in 10 ml, give 1 ml
every minute, steroids,
volume, volume, volume
Protamine (cross reaction with NPH insulin)
give test dose

Hypotension
Think Think of hypovolemia (bleed and
dehydration), tamponade (esp.
with TTVP)
Vasovagal Vasovagal reaction, anaphylaxis,
occlusion
Treat Treat per diagnosis

Retroperitoneal Hematoma
Uncontrolled free bleeding usually means
laceration of the artery: change sheath,
remove sheath and compress
Puncture above the inguinal ligament may
lead to retroperitoneal hematoma
(Puncture using Fluoro)
Rx: CT scan, transfusion, occasional surgical
decompression, reverse IIbIIIa & heparin

Pseudoaneurysm and and AV AV Fistula Fistula
Frequency 1 - 2%
< 2 cm. Usually close spontaneously
90% close with compression
Thrombin injections
Surgery rarely needed
Prevention: Accurate puncture and initial
control of the bleeding with sheath upsize
and early removal

Iliac Iliac Dissection or or Perforation
Generally occurs during retrograde passing of
wires and catheters through tortuous or stenotic
arteries
If these dissections are retrograde and small,
usually the forward blood flow will tag down the
dissection flap
If persists or flow limiting, can be treated by
stenting
Perforation: seal with PTA balloon, then operate
or put covered stent

What What are are the the Steps Steps that that can can be be taken taken to to
Minimize Complications?
Ischemia:
Embolism:
Slow Flow:
IABP with LM, Decreased EF
Diffuse calcium with Roto
Embolectomy Catheters
IIbIIIa inhibitors
ADP inhibitors
IIbIIIa inhibitors
Distal Protection
Thrombectomy
Prophylactic Ca ++ Prophylactic Ca blockers, Nipride,
++ blockers, Nipride,
or adenosine preloaded on
delivery catheters

What What are are the the Steps Steps that that can can be be taken taken to to
Minimize Complications Cont...?
Side Branch Occlusion:
Perforations:
Renal Failure:
Debulking
Dual Stents
Avoid Stenting
Coils
Covered Stents
Contrast agents
Small guides
Hydration and diuresis

Preprocedural Risk Risk Assessment
Conceptual Framework
Should I Perform the Procedure?
Absolute
1. Risk to the Patient
Rate of Death or MACE per 100
Rate of “Minor” Complications
Long Term Risk of Death, MI, & TLR

Preprocedural Risk Risk Assessment
2. Risk to the Patient -
Relative Risk
Risk of PTCA vs. Alternative Therapies
(Surgery or Medical Rx) for Short and
Long Term Complications

Preprocedural Risk Risk Assessment
3. Risk to the Operator
Adverse Outcomes on Physician
Profile for Hospital Privileges, Payor
Contracts, and Public Relations

What What are are Procedural Complications?
Ischemia
Acute Closure
Embolism
Side Branch Occlusion
Slow / No Flow
Perforation
Other
SAT
Renal Failure

What What are are Procedural Complications?
Wire Crossing
Thrombosis
Severe/Angulated Stenosis
Poor Visualization
After Wire Crossing
Dissection, thrombus, major stroke,
branch closure
Can we deliver a stent?
Calcium
Tortuosity
Poor guide support
}Potential Potential for getting
caught with your
pants down! (i.e.
closure without
distal protection)

Correlates of of Adverse Outcomes
Old
Small / large
USA
Female
Low LVEF
SVG
Thrombus
Clinical
CHF
Angiographic
Emergency
PVD
RF
Calcification
Bifurcation
Tortuosity

Summary
Intra-procedural complications can be prevented
and minimized (but not eliminated) with today’s
technology and careful planning.
Acute and long term mortality are determined
primarily by clinical factors not controlled by the
operator.
Consideration of short and long term risks to
patients must be assessed taking both these facts
into consideration.
These risks, when compared to therapeutic
alternatives, will lead to optimal outcome for
patients.