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Table of Contents
ORIGINAL ARTICLE
Year : 2018  |  Volume : 1  |  Issue : 1  |  Page : 40-44

Early and late outcomes of coronary stent graft: A 15-year experience from a single center


Department of Cardiology, LSU Health Sciences Center, Shreveport, Louisiana, USA

Date of Web Publication24-Aug-2018

Correspondence Address:
Dr. Kalgi Modi
Department of Cardiology, LSU Health Sciences Center, 1501 Kings Highway, Shreveport, LA 71103
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IHJI.IHJI_5_18

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  Abstract 

The study reviewed the outcomes of patients treated with covered stent for coronary artery perforation (CAP). CAP is an infrequent and life threatening complication of percutaneous coronary intervention. It can result in abrupt vessel closure, acute iatrogenic pericardial effusion, cardiac tamponade and death if not recognized and managed promptly. Placement of coronary stent graft is the cornerstone of management of CAP. Coronary stent graft is a humanitarian device, authorized by federal law for use in the treatment of perforation in a vessel ≥ 2.75 mm in diameter causing free contrast extravasation into the pericardium. The use of this device is associated with a risk of acute and subacute thrombosis. We report five cases of CAP that were effectively treated with either coronary stent grafts or prolonged balloon inflation with two of them subsequently developing stent graft thrombosis and literature review on efficacy and safety of stent grafts.

Keywords: Coronary perforation, covered stent, cardiac tamponade


How to cite this article:
Modi K, Morris L. Early and late outcomes of coronary stent graft: A 15-year experience from a single center. Indian Heart J Interv 2018;1:40-4

How to cite this URL:
Modi K, Morris L. Early and late outcomes of coronary stent graft: A 15-year experience from a single center. Indian Heart J Interv [serial online] 2018 [cited 2018 Dec 14];1:40-4. Available from: http://www.ihji.org/text.asp?2018/1/1/40/239782




  Introduction Top


Coronary artery perforation (CAP) is an infrequent and life-threatening complication of percutaneous coronary intervention (PCI) requiring prompt intervention.[1] Perforation can result in abrupt vessel closure, acute iatrogenic pericardial effusion, cardiac tamponade, and death if not recognized and managed promptly. In addition to emergent needle pericardiocentesis for cardiac tamponade, cessation and reversal of anticoagulation when appropriate, prolonged balloon inflation, and placement of coronary stent graft are the cornerstones of management of CAP. Coronary stent graft is a humanitarian device, which is authorized by federal law for use in the treatment of perforation in a vessel ≥2.75mm in diameter, causing free contrast extravasation into the pericardium. The use of this device is associated with a risk of acute and subacute thrombosis. We report case series of CAP that were effectively treated with either coronary stent grafts or prolonged balloon inflation with two of them subsequently developing stent graft thrombosis, and literature review on the efficacy and safety of stent grafts.


  Study Design Top


We retrospectively reviewed our electronic database of coronary PCI from June 2002 to March 2017. The study was approved by the local institutional review board. All cases of type I, II, and III coronary perforations were identified by manually searching the electronic PCI database and paper logbook. A detailed review of all coronary angiograms and relevant clinical documentation was performed for study cases. Coronary interventions were performed using standard techniques, and dual antiplatelet therapy (DAPT) with aspirin and clopidogrel/ticagrelor/prasugrel was continued following the intervention in all study cases. An emergency echocardiogram was performed in all cases after the perforation was recognized.


  Results Top


During a 15-year period, between 2002 and 2017, we performed 5200 PCIs. There were five patients with type III coronary perforation, five patients with type II coronary perforation, and one patient with type I coronary perforation, leading to an incidence of 0.2%. No case of saphenous vein graft perforation was recorded. The clinical demographics and angiographic characteristics of 5 of 11 patients with type III perforation are presented in [Table 1] and [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]. Two patients presented with non-ST-elevation myocardial infarction (NSTEMI), whereas the others presented with unstable angina and stable angina. Three of the five patients with type III perforation required emergent needle pericardiocentesis for tamponade. Four patients were effectively treated with coronary stent graft (JOSTENT; Abbott (Chicago, Illinois, USA)) after prolonged balloon inflation failed to control bleeding. Patient 1 who presented with an acute anterior ST-elevation myocardial infarction (STEMI) 8 days after index procedure had subacute stent graft thrombosis and was successfully treated with balloon angioplasty using noncompliant balloons. Patient 4 who developed an inferior STEMI 2h after index procedure had acute stent graft thrombosis, and despite successful treatment with high-pressure balloon angioplasty using noncompliant balloons, subsequently died of cardiogenic shock, thus causing our perforation mortality to be at 9% (reported average from 2.6% to 17%).[2]
Table 1: Clinical demographics and angiographic characteristics

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Figure 1: (A) Patient 1 with >90% bifurcating lesion of mid–left anterior descending (LAD) coronary artery and diagonal 2. (B) Type III perforation from mid-LAD (red arrow). (C) Perforation sealed after two JOSTENTs with loss of diagonal 2

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Figure 2: (A) Patient 2 with 80%–90% in-stent restenosis of the second obtuse marginal artery (OM2) stent. (B) Perforation after post-dilatation of newly placed stent (red arrow). (C) Perforation sealed after prolonged balloon inflation

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Figure 3: (A) Patient 3 with 70%–80% mid-OM2 stenosis. (B) Perforation after stent placement (red arrow). (C) Perforation sealed after JOSTENT placement with loss of the distal circumflex (red arrow)

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Figure 4: (A) Patient 4 with >90% mid– right coronary artery (RCA) stenosis. (B) Perforation after post-dilatation of two newly placed overlapping stents (red arrow). (C) Perforation sealed after two overlapping JSTENTs

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Figure 5: (A) Patient 5 with physiologically significant distal LAD stenosis. (B) Perforation after stent placement (red arrow). (C) Perforation sealed after JOSTENT placement with evidence of a contained coronary pseudoaneurysm)

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CAP is a rare but life-threatening complication of PCI affecting 0.19%–1.5% of cases.[2] The three types of perforation are as follows: type I, extraluminal crater without extravasation; type II, pericardial or myocardial blush without contrast extravasation; and type III, extravasation through frank (≥1mm) perforation and cavity spilling into an anatomic cavity chamber, coronary sinus, and so on.[3] Type I perforation though frequently unrecognized is benign in nature, and thus requires no specific intervention. Types II and III are lethal in nature because of associated risk of cardiac tamponade. Mortality rates following grade III perforation range from 7% to 44%. Several factors can be associated with CAP: (1) clinical variables: advanced age, female gender, renal dysfunction, and NSTEMI; (2) angiographic factors: chronic total occlusion, coronary artery calcification, tortuous vessels, target lesions in the circumflex and right coronary arteries, long target lesions (>20mm), and eccentric lesions; and (3) technique-associated factors: use of hydrophilic/extra stiff wires, atherectomy devices, increased balloon-to-artery ratio, intravascular ultrasound (IVUS)-guided PCI optimization and high-pressure stent post-dilatation, percutaneous excimer laser coronary angioplasty, and cutting balloons.[4] Type I and II perforations are predominantly caused by hydrophilic or stiff distal guide wire trauma. Type III perforation is more often associated with stent placement or atheroablative devices. We found a combination of female gender, cutting balloon, and high-pressure stent inflation to be culprit factors in our series.

Traditional management of CAP consists of prolonged balloon inflation (proximal to or at the site of perforation to prevent tamponade) and reversal of anticoagulation with protamine. It has been reported that the administration of protamine in patients with CAP seems to be safe, without an increase in the risk of vessel thrombosis/stent thrombosis (ST). Continuation of antiplatelet therapy is not associated with overt rebleeding.[5] In a meta-analysis of three randomized trials, no significant difference was found in complicated CAP between bivalirudin monotherapy and the use of unfractionated heparin plus glycoprotein IIb/IIIa inhibitors.[6] Pericardiocentesis must be performed promptly if tamponade occurs. In rare cases, surgical repair of CAP comprises either ligation or suturing of the vessel or pericardial patch and bypass grafting to the distal portion of the vessel.[5] The use of polytetrafluoroethylene-coated stent grafts is less invasive, faster, and more effective when compared to surgical interventions and is generally considered to be the gold standard in the management of type III CAP. The incidence of subacute thrombosis (5.5%–33%) and restenosis (30%–50%) of the stent grafts is relatively higher than that of the conventional coronary stents, which may be related to delayed endothelialization and increased susceptibility to thrombus formation in these stents.

In our study, early ST was seen in two patients (18%). One ST occurred at 8 days after covered stent implantation, and the other occurred 2h after covered stent implantation and resulted in cardiac death. Briguori et al.[7] reported that IVUS, final high-pressure balloon inflation, and prolonged DAPT might be associated with the lack of thrombo-occlusive events. In each case, DAPT was continued up until the time of event. In our study, IVUS was used only in one patient, although post-dilation was performed in all the patients. Using IVUS more frequently may have further reduced the rate of ST. At 18-month follow-up, no cases of late ST or target vessel revascularization were observed.

Coronary pseudoaneurysm is a rare finding as a complication of PCI. Only a few cases on the management of post-PCI coronary pseudoaneurysms are reported in the literature.[8] Because of the lack of knowledge of the natural history and the risks associated with coronary pseudoaneurysms, our patient with coronary pseudoaneurysm was treated with a covered stent graft.

In conclusion, coronary perforation is a rare but life-threatening complication of PCI. In this emergency setting, despite the relatively high incidence of ST during the early stage of follow-up, implantation of a cover stent provides acceptable late clinical outcomes.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Aykan AÇ, Güler A, Gül I, Karabay CY, Alizade E, Gökdeniz T, et al. Management and outcomes of coronary artery perforations during percutaneous treatment of acute coronary syndromes. Perfusion 2015;1:71-6.  Back to cited text no. 1
    
2.
2.Topol EJ, Teirstein PS. Textbook of interventional cardiology. 7th ed. Philadelphia, PA: Elsevier/Saunders; 2016.  Back to cited text no. 2
    
3.
Ellis SG, Ajluni S, Arnold AZ, Popma JJ, Bittl JA, Eigler NL, et al. Increased coronary perforation in the new device era. Incidence, classification, management, and outcome. Circulation 1994;1:2725-30.  Back to cited text no. 3
    
4.
Ekici B, Erkan AF, Kütük U, Töre HF. Successful management of coronary artery rupture with stent-graft: A case report. Case Rep Med 2014;1:391843.  Back to cited text no. 4
    
5.
Al-Mukhaini M, Panduranga P, Sulaiman K, Riyami AA, Deeb M, Riyami MB. Coronary perforation and covered stents: An update and review. Heart Views 2011;1:63-70.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Doll JA, Nikolsky E, Stone GW, Mehran R, Lincoff AM, Caixeta A, et al. Outcomes of patients with coronary artery perforation complicating percutaneous coronary intervention and correlations with the type of adjunctive antithrombotic therapy: Pooled analysis from REPLACE-2, ACUITY, and HORIZONS-AMI trials. J Interv Cardiol 2009;1:453-9.  Back to cited text no. 6
    
7.
Briguori C, Nishida T, Anzuini A, Di Mario C, Grube E, Colombo A. Emergency polytetrafluoroethylene-covered stent implantation to treat coronary ruptures. Circulation 2000;1:3028-31.  Back to cited text no. 7
    
8.
Nunes RA, Cadea JR, Silva RC, Brito Júniora FS, Freitasa HF. Spontaneous closure of post-intervention left anterior descending coronary pseudoaneurysm. Rev Por Cardiol 2014;1:381.e1-4.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

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