COMPLICATION

PERCUTANEOUS CORONARY INTERVENTION

Yusra Pintaningrum
Faculty of Medicine, Mataram University – RSUD Provinsi NTB
Fellowship Interventional Cardiology – RSUD Dr Soetomo Surabaya
 Background
• PCI may be challenging and complicated
• Improvements in devices, the use of stents, and
aggressive antiplatelet therapy have significantly
reduced the incidence of major periprocedural
complications of PCI over the past 15 to 20 years
• The need for emergent CABG decreased in two series:
from 1.5 % in 1992  0.14% in 2000
from 2.9% in 1979 to 1994  0.3% in 2000 to 2003

Joseph, 2016
 EDUCATIONAL CONTENT ENDORSED BY EAPCI,
A REGISTERED BRANCH OF THE EUROPEAN SOCIETY OF CARDIOLOGY

The New York State PCI registry 1999-2006

© 2016 Europa Digital & Publishing. All rights reserved.

The PCR-EAPCI Textbook – Percutaneous interventional cardiovascular medicine
The prevention and management of complications during percutaneous coronary intervention
Rodney De Palma, Christian Roguelov, Adel Aminian, Olivier Muller, Tito Kabir, Eric Eeckhout
 EDUCATIONAL CONTENT ENDORSED BY EAPCI,
A REGISTERED BRANCH OF THE EUROPEAN SOCIETY OF CARDIOLOGY

Periprocedural complications within 24 hours

© 2016 Europa Digital & Publishing. All rights reserved.

The PCR-EAPCI Textbook – Percutaneous interventional cardiovascular medicine
The prevention and management of complications during percutaneous coronary intervention
Rodney De Palma, Christian Roguelov, Adel Aminian, Olivier Muller, Tito Kabir, Eric Eeckhout
 EDUCATIONAL CONTENT ENDORSED BY EAPCI,
A REGISTERED BRANCH OF THE EUROPEAN SOCIETY OF CARDIOLOGY

Broad Mechanisms that lead to complications

© 2016 Europa Digital & Publishing. All rights reserved.

The PCR-EAPCI Textbook – Percutaneous interventional cardiovascular medicine
The prevention and management of complications during percutaneous coronary intervention
Rodney De Palma, Christian Roguelov, Adel Aminian, Olivier Muller, Tito Kabir, Eric Eeckhout
 Complication PCI
Patient preparation
and selection

During the procedure

Vascular
complications
Patient Preparation and Selection

Contrast reactions

diabetes

Left ventricular dysfunction and shock

Acuity of presentation

Renal insufficiency

Peripheral vascular disease

Anaemia
During procedure
Dissection and abrupt closure after PTCA

perforation

Distal embolization

Complication seen with stenting

• Stent thrombosis , stent dislodgement
Vascular Complications
Retroperitoneal bleeding

Pseudoaneurisma

AV fistula

Infection

Hematome

dissection

Lower extremity ischaemia

 Case 1
BALLOON DETACHMENT
 Case ilustration
• A 57 year-old , male
• Hypertension (+) for 10 years
• ECG : SR 85 bpm, anterior extensive old
myocard infarction
• CXR : CTR 65%
Coronary Angiography
Old Stent Patent
at proximal LAD

Old Stent Patent

At proximal LCX
CTO at proximal-mid RCA
- GW Runthrough NS hypercoat
- Microcatheter finecross
- Balloon Across CTO 1.5x10 mm
- Balloon Across CTO 1.1x10 mm
- Anchor balloon CTO 2.5 x 15 mm to
SN
- Buddy wire to distal RCA
- Balloon Saphire 1.0x15 mm 
balloon Across CTO 1.5x10 mm 
balloon Mozec 2.0x9 mm distal to
proximal RCA 

balloon detachment
 Capture Balloon

Two wire technique

Dislodged stent in the wire A second wire is advanced through

the stent strut or beside the stent

Twisting the two wire together, Withdraw the two wires with the stent to
the twisted end can trap the stent guiding catheter then the whole system
Balloon Detachment
 FINAL RESULT

Stent DES Ultimaster 2.75x33 mm

Stent DES Ultimaster 2.5 x 33 mm

No Residual Stenosis
TIMI Flow 3
No Complication
 Case 2
STENT DISLODGEMENT
 Illustration Case
• Male 61 years old
• stable angina
• Comorbidities
– Hypertension
– dyslipidemia
– heavy smoker.
• ECG : inferior old myocardial infarction.
Stenosis 60% distal LM

Stenosis 70% osteal LCX

CTO distal LCX

Diffuse disease LAD

Diffuse disease
Subtotal stenosis mid RCA
 GC JR 4.0 6F
GW pilot 60
Balloon Saphirre II 1.5x15 mm

Stent BMS Apollo 3.0x 36 mm

 stent dislodgement

Stent DES Firebird II

 Stent dislodgement

“Small balloon technique”

 FINAL RESULT

Stent BMS Arthos PICO 3.0x34 mm

Stent DES Firebird II

 Stent Dislodgement / stent loss
• The incidence : 3.4% (earlier)  0.32% (recent)
• 11,773 PCI cases (January 1994 and March
2004)
– Stent loss : 38 (0.32%; 95% CI = 0.23-0.44%).
• Successful stent retrieval : 35
• Stent loss occurred more frequently in lesions
with calcification and/or significant proximal
angulation.

Korean Circ J 2010;40:405-409

Catheter Cardiovasc Interv. 2005 Nov;66(3):333-40.
 MECHANISM STENT LOSS

Brilakis, Garratt
http://thoracickey.com/device-loss-during-percutaneous-coronary-intervention-incidence-complications-and-retrieval-methods/
 How to retrieve the stent loss?
according successful stent retrieval (%)

advancing a balloon through

the stent, inflating the
balloon, and withdrawing the
stent (45%)
Cook retained fragment
retriever (10%)
loop snare (26%) biliary forceps (12%)
twirling two wires basket retrieval device (2%)
around the stent (5%)

Catheter Cardiovasc Interv. 2005 Nov;66(3):333-40

(PubMed.gov)
 Homemade snare

GW exchange 300 mm
Diagnostic Catheter 4-5 Fr
(usually multipurpose)

Brilakis, Garratt
http://thoracickey.com/device-loss-during-percutaneous-coronary-intervention-incidence-complications-and-retrieval-methods/
How to anticipate the
complication of PCI?
 EDUCATIONAL CONTENT ENDORSED BY EAPCI,
A REGISTERED BRANCH OF THE EUROPEAN SOCIETY OF CARDIOLOGY

Risk stratification tools using

combination of patient and lesion characteristics

© 2016 Europa Digital & Publishing. All rights reserved.

The PCR-EAPCI Textbook – Percutaneous interventional cardiovascular medicine
The prevention and management of complications during percutaneous coronary intervention
Rodney De Palma, Christian Roguelov, Adel Aminian, Olivier Muller, Tito Kabir, Eric Eeckhout
 EDUCATIONAL CONTENT ENDORSED BY EAPCI,
A REGISTERED BRANCH OF THE EUROPEAN SOCIETY OF CARDIOLOGY

Complication ‘Tool-Box’

© 2016 Europa Digital & Publishing. All rights reserved.

The PCR-EAPCI Textbook – Percutaneous interventional cardiovascular medicine
The prevention and management of complications during percutaneous coronary intervention
Rodney De Palma, Christian Roguelov, Adel Aminian, Olivier Muller, Tito Kabir, Eric Eeckhout
 EDUCATIONAL CONTENT ENDORSED BY EAPCI,
A REGISTERED BRANCH OF THE EUROPEAN SOCIETY OF CARDIOLOGY

Schema for illustrating the risk of complications associated with a procedure

© 2016 Europa Digital & Publishing. All rights reserved.

The PCR-EAPCI Textbook – Percutaneous interventional cardiovascular medicine
The prevention and management of complications during percutaneous coronary intervention
Rodney De Palma, Christian Roguelov, Adel Aminian, Olivier Muller, Tito Kabir, Eric Eeckhout
 Conclusion
• Periprocedural complications within 24 hours :
major 4.1% and minor 7 %
• The risk of complication relating procedure:
Patient-equipment-operators related factors
• Attention to prevention, recognition and
treatment of these complications is essential
An intervensionist can be called expert after dealing with
complicated cases of PCI and cases of PCI with
complications
• THANK YOU