Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download PCI Complications
Document related concepts
Remote ischemic conditioning wikipedia , lookup
Coronary artery disease wikipedia , lookup
Cardiac surgery wikipedia , lookup
Myocardial infarction wikipedia , lookup
Management of acute coronary syndrome wikipedia , lookup
Quantium Medical Cardiac Output wikipedia , lookup
History of invasive and interventional cardiology wikipedia , lookup
Transcript
PCI Complications ROSLI Mohd Ali Head Department of Cardiology National Heart Institute Kuala Lumpur BX Velocity Stent 3.5 x 18 at 16 Atm Peak CK – 7797 u/L Mid LAD stenosis 2002 58 yr lady Direct stenting with AVE S7 3.0 x 24 mm What would you do? PCI Procedural Success 1. Angiographic (anatomical) success 2. Without clinical complications Angiographic (anatomical) success: • minimal luminal diameter < 10% stenosis • TIMI 3 flow Without clinical complications • MACE (major adverse cardiac events) • MACCE (major adverse cardiac & cerebrovascular events) PCI Clinical Complications MACE (major adverse cardiac events) composite of death, MI or emergency revascularisation MACCE (major adverse cardiac & CV events) composite of death, MI, emergency revascularisation or stroke Classification of Complications Category Mechanism Coronary injury acute/threatened closure no reflow phenomenon perforation retained equipment arrhythmia Non-coronary Injury iatrogenic aortic dissection peripheral neovascular injury embolisation (stroke/limb ischaemia) nephropathy radiation injury Systemic event vasovagal reaction anaphylaxis haemorrhage acute pulmonary oedema sepsis PCI Complications Rates Gruentzig original 50 pts 1977 14 % NHLBI PTCA Registry 1985 6.6 % New York State PCI Registry 1999 – 2006 Overall complications 3.36 % Mortality in Cath. Lab at one month 0.047 % 0.6 % PCI Complications Rates: NY State Registry 1999 – 2006 n - 23,339 procedures Causes Death 1 mo post PCI Death in cath. lab Stroke Cardiac perforation Any MI Emergent surgery Stent thrombosis at 1 mo Presumed stent thrombosis Renal failure Haemodialysis Retroperitoneal bleed Vascular complication & bleeding 1 mo composite with ST 1 mo composite without ST % 0.6 0.047 0.29 0.29 0.74 0.15 0.53 0.82 0.28 0.17 0.18 0.79 1.8 1.58 Any Complication 3.36 PCI Complications Prevent, Anticipate, Recognise & Manage Patient Factor: Frailty, old age Co-morbid conditions eg renal failure, DM, COPD, PVD Cardiogenic shock Obesity Anticoagulation Lesion Factor: LMS disease Multivessel disease Diffuse lesions Thrombosis CTO Calcified PCI Complications Prevent & Manage To reduce mortality & morbidity Drs & Allied Staff • knowledgeable • discussion about patient & procedure • have devices ready • focus on patient during procedure • willing to inform of any changes hemodynamic, ECG, patient’s condition angiographic abnormalities Long total prox. - distal LAD occlusion 42 yr old man Following 2 Drug-eluting Stents 2 GDC coil embolization Perforation Perforation Potential treatment If suspect tamponade, confirm with echocardiogram. Perforation • Long balloon inflation • Reverse heparin protamine sulphate 1 mg per 100 units heparin • Persistent perforation distal – coil embolisation, glue, fat tissue mid - covered stent, sandwich stents emergency surgery CARE with Gp IIb/IIIa inhibitor !! Pericardiocentesis Perforation Perfusion balloon (prolonged inflation time) Site proximal / mid: Covered stent Site distal: Coil 21 July 2011, 10:38:28 am, IJN 248 min fr. onset of chest pain In cardiogenic shock. SBP 80 mmHg Thromboaspiration Thrombuster Kaneka BMS 3.5 x 18 mm Final Results 4 inotropes Died 10 hrs later 302194 (6 Sept 13) 54 yr old man Anterior STEMI D3 TRI Castillo 2 6 Fr (diagnostic) EBU 3.5 6 Fr BMW Runthrough Floppy 2.5 x 20 mm Xience Xpedition 3.0 x 48 mm 16 Atm Causes of Slow Flow? Causes of Slow Flow? 1. 2. 3. 4. 5. 6. 7. Distal dissection Spasm Distal embolization Poor distal run-off (loss of branches) High LVEDP Hypotension Wire biasness Rewired into D1 Thrombuster 6 Fr NC 3.0 x 18 mm at 20 Atm Injection through thrombuster Adenosine bolus Through thrombuster (went to transient standstill) + NTG 299279 (11 June 13) 67 yr old man AL1 6Fr Conquest Pro wire Runthrough Floppy (anchor wire) POBA 1.5 x 15 mm JR 3.5 6 Fr Biomatrix 3.0 x 33 mm Biomatrix 3.0 x 33 mm Biomatrix 3.0 x 18 mm Endeavor 3.5 x 12 mm What Do You Do For the Aortic Dissection? Thrombotic lesions? 52 yr old man with post-infarct angina 1 wk after inferior MI PCI 3rd April 2007 Aspirated with Export cath 7F Balloon dilatation 3. Thrombus Do We Stent All Lesions? Concerns with distal embolization PCI Cases: when do we stop? 3rd April ‘07 1 week of sc enoxaparin 10th April ‘07 Continued with oral anticoagulation Ischaemic test planned in the future After thromboaspiration (Thrombuster) & balloon Angiojet Thrombectomy Device Bernoulli Principle Where the velocity is the greatest, the pressure is the lowest Angiojet Thrombectomy Device Iatrogenic Coronary Thrombosis Avoiding Risk keep equipment dwell time to a mininum wipe all exteriorised equipment before reintroduction Flush all introducers & catheters regularly Heparin before PCI weight adjusted dose (70 units/kg – check ACT every 30 min 100 units/kg – ACT after one hour) Check ACT when time arrives Stented LMS to LAD 3.5 mm DEB Sequent Please LMS to LAD 3.0 x 20 mm Sequent Please 3.0 x 30 mm Stent 3.5 x 12 mm Kissing LAD 3.5 mm LCx 3.0 mm Losing Side-branch Pre PCI Post PCI SMART Stent 8 x 80 mm Radial artery damage - Perforation: Incidence 0.1 – 1% Tortuous and looping Spasm Anomalous anatomy Hydrophilic wires Catheters Often a matter of feel If in doubt: Fluoroscopy & take an angiogram! Put in a long sheath Complications of the Radial Approach Radial artery damage- Perforation: MIDFOREARM HAEMATOMA Haematoma Acute Occlusion Angiojet Post-Angiojet Long aorto-iliac Stenosis Calcified vessels Direct Stenting in Hugging Fashion Long Wallstents 10 mm in diameter 8 mm x 40 mm 8 mm x 40 mm At 8 Atm 8 mm x 40 mm At 12 Atm Hypotensive SBP dropped from 120 – 130 to 70 mmHg Patient getting restless BP dropped whenever balloon deflated Forgot to bring Jomed covered stent graft !! Saved !! Wallstent graft 11 mm x 50 mm No 11 F sheath !! BP Stabilized No further drop BP stabilized Transfused 4 pints of pack cells CT scan – blood in pelvic cavity Discharged a few days later Conclusions Can’t avoid complications! Prevent & manage them well • • • • • • • • • • Select patient & lesion well. Anticipate problems & plan strategy well Good guiding catheter Good angiographic views Know your equipment well Have them available Keep the procedure as simple as possible Know your own limitations Know when to stop Learn from one’s own & other’s mistakes You are part of the team!! 290530 (19 Dec 12) 60 yr old lady 384575 (Outside IJN) 11 June 11 38 65 yr old lady
