My Most Instructive Complication of the Year Douglas E. Drachman, MD, FSCAI Massachusetts General Hospital Boston, MA
Disclosure Information Douglas E. Drachman, MD, FSCAI Abbott Vascular, Inc: Advisory Board Corindus Vascular Robotics: Advisory Board St. Jude Medical: Consultant Atrium Medical Corporation: Research Grant Support Lutonix/BARD: Research Grant Support Off label use of products will be discussed in this presentation as indicated. Many stents used in the peripherial arterial circulation are indicated for biliary or tracheal application. Drachman 2015
HPI 71yo woman with HTN, HLP, PVD, CVD, RAS presents with exertional CP ETT-MIBI: 3 21 SB, CP+, mhr 136, pbp 142/80mmHg 1mm STd II, III, avf, v4-v6 Medium sized severe ischemia mid and basal inferolateral and basal anterolateral walls Medications: aspirin 81 mg tab oral daily metoprolol extended release 25 mg 24 hr XR tab 1 oral simvastatin 40 mg tab oral qpm clonidine 0.1 mg 1 oral bid hydrochlorothiazide 25 mg tab 1 oral daily
Cath at OSH Separate LAD ostium 90% mid LAD
Cath at OSH Separate LCx ostium 80% mid OM1
Cath at OSH RCA 90% mid
OSH Evaluation Recommended CABG She declined, sought 2 nd opinion at MGH MGH cardiologist suggested targeted PCI of RCA
Cath at MGH: Note LCX ostium
Ad hoc re-discussion with Primary Cardiologist: Reconsider CABG? She declined CABG LCX vs. RCA as culprit Fix the RCA, let s see how she does Foreshadowing: Role/responsibility of interventional team Relationship with referring MD Pre-procedural discussion with patient
RCA PCI: Plan: Right transradial access 6F AL 0.75 guide 0.014 RunThrough PTA/stent
RCA PCI: Execution: Wire seized in angulated lesion Could not advance 1.5mm balloon Could not advance a buddy wire FineCross would not pass Bear Trap lesion Suboptimal guide support
RCA PCI: Execution (plan B): Guideliner 1.2mm PTCA Freed wire (advanced to PDA)
RCA PCI: Execution (Plan B): Guideliner 1.2mm PTCA Freed wire (advanced to PDA) Routine PTCA 2.5 x 32mm DES 2.75mm NC post-dil ROTA REGRET
One month later She has persistent symptoms Could you try to fix the LCX? Foreshadowing: Revisit the CABG discussion Continue with targeted approach (1-2 more lesions ) Risk/benefit of complex LCX lesion Rota Regret from RCA experience Plan: LCX Rota, PTCA, stent (protect LAD ostium)
LCX PCI: Plan: Left transradial access 6F CLS 3.0 guide 0.014 RunThrough in LAD
LCX PCI: Plan: Left transradial access 6F CLS 3.0 guide 0.014 RunThrough in LAD Air mail second RunThrough to LCX Walk guide over
LCX PCI: Execution: Advance Fielder FC to distal LCX Exhange for RotaFloppy wire 1.25mm burr
LCX PCI: Execution: Advance Fielder FC to distal LCX Exhange for RotaFloppy wire 1.25mm burr
LCX PCI: Execution: Burr stalled on 2nd run after prox turn Manually retracted Guide floated free Rota wire=severed Re-wire LAD
LCX PCI: Execution: Burr stalled on 2nd run after prox turn Manually retracted Guide floated free Rota wire=severed Re-wire LAD Air mail wire to LCX
LCX PCI: Execution: Fielder FC to distal LCX Balloon tamponade LCX perforation Persists after 10 min
Status update Persistent perforation after 10 min PTCA Patient: minimal symptoms, some ST depression Hemodynamics relatively stable STAT echo (no effusion seen) Echo cord draped over patient s left wrist (access) We ordered 1g Ancef IV RN gave Angiomax by mistake, noted after ½ bag ACT= 523 sec
LCX PCI: Execution: More brisk extravasation after Angiomax
Next steps? Retrieve fractured Rota wire? Snare: would lose PTCA balloon tamponade, or would require a second ping-pong guide Multiple wires, braiding: would lose PTCA balloon tamponade and potentially guide access Ambiguous location of proximal end of Rota wire Leave the wire in place?
LCX PCI: Execution: Second Fielder FC to distal LCX Intermittent release of tamponade PTCA FineCross exchange of Fielder FC for Wiggle Wire PTCA/DES of mid LCX
LCX PCI: Execution: Quickly advance, position Graftmaster 2.8 x 16mm to cover perforation
LCX PCI: Execution: After Graftmaster post-dilated 3.0mm to seal the perf DES to LCX ostium Avoid crossing LAD ostium
Final result after 3.0-3.5mm NC
Epilogue Uneventful recovery Repeat echo: no effusion Remains angina free (2 months later)
Additional points: Discussion of adverse events with patient Device malfunction Perforation, potential harm Retained wire (unknown long term impact) Medication dosing error Incident report for hospital QA Reporting to FDA for device evaluation (save wire, Rota burr)
Additional points: Appropriate follow-up? Re-look? Expectant? Lifelong DAPT to protect the wire? Can anything be done for the LCX if wire-related issues? What if she has recurrent angina from LAD? Rota? Any better solutions for management? Reversal of heparin (if no Angiomax) Retrieval of wire Other