Presentation Time: 1605-1620
Nor Halwani HABIZAL (1), Dr Kamaraj Selvaraj (1), Dr Asri Ranga (1), Dr Abdul Muizz (1), Dr Abdul Kahar(1)
A TWISTED PRIMARY PCI
Nor Halwani HABIZAL
Institut Jantung Negara
Asia CC Complication Case
71 year old gentleman with no medical history presented to ED with complaint of chest pain. ECG performed noted lateral myocardial infarction and Primary PCI Network was activated.Radial angiogram with optiorque showed Distal LAD 30% stenosis with Ostial LAD 20% stenosis and OStial LCX 80% stenosis. While trying to engage RCA the optitorque was kinked in the brachial artery and attempted to unkink with manual compression and wire with 0.035 wire. As this was a primary PCI time was not wasted and proceeded with femoral puncture to continue angiogram. RCA was non dominant with mild disease. PCI to LCX which was the most significant lesion was performed. Wired with sion blue to LAD and rinato to LCX and predilated with scoring balloon 2.75x15mm. LM to LCX was stented with xposition 3.5-4.5x17mm due to the large diameter in vessel and wires was flip flop and potdilated with 5.0x12mm balloon.
Procedure was uneventful and we shifted to retrieve the kinked optitorque at the brachial artery. As we have tried and failed with manual compression and 0.035 wire we decided to snare the tip of optitorque to straighten and unkink it. We didn’t want to attempt again with fear of blood clot in the catheter which may cause embolic stroke. If at all the optitorque snap we can also snare the broken catheter at the same time. From the femoral we used the JR catheter with 25mm goose snare and was able to snare the tip of the optiroque. As we pulled the optitorque to straighten it there was a felt of unkink and immediate blood flow was seen at the optitorque. Optitorque was able to be pulled out from radial without complication and subsequent angiogram didn’t show any dissection or perforation. Primary PCI is a medical emergency and procedure should be done quickly and safely. In this case the optitorque was kinked and we proceeded with femoral route with minimal time wasted. The removal or kinked optitoque could be dangerous and catheter could break or dissection or even perforation. Snaring is safe option with minimal complication.
Presentation Time: 1621-1636
Dr. Chu CM (1), Dr. Liew HB (1)
Chu Chong Mow
Sabah Heart Centre – Queen Elizabeth Hospital
Asia CC Complication Case
Demonstrate ostial stenting using self-apposing stent
Demonstrate the complication of stent migration
Demonstrate snaring of migrated stent and discuss alternative strategy
51 year old man with past medical history of hypertension and gout. He presented to Sandakan hospital with inferior MI. He was thrombolysed successfully however complicated with cardiogenic shock VF requiring cardiopulmonary resuscitation. He survived and later transferred to SHC-QE2 for further management. On examination his BP was 118/78, P 52, Sat O2 99%. Cardiovascular examination was unremarkable. Blood investigation normal except for mild renal derangement. His LVEF 50-55% valves were normal. He underwent routine angiogram with 6Fr radial sheath. Diagnostic angiogram showed TVD.
LAD :Proximal 70-80% stenosis
LCx :Distal subtotal stenosis
RCA :Dominant. Proximal 50-60% stenosis. Distal 80-90% stenosis.
Ad hoc PCI was performed in view patient from far and the CABG waiting list was long. 6Fr JR 4 used to engage the RCA. BW wire and Sion wire pass distal to PDA and PLV. dRCA predilated with NC balloon 2.5 x 12mm. dRCA and PLV stented with DES 3.5 x 38mm. Post-dilatation with NC balloon 3.75 x 15mm. PDA rewired. POBA of ostial PDA with NC balloon 2.5mmx. Final Kissing performed with NC balloon 3.75mm and 2.5mm. Upon completion of procedure noted a small non flow limiting dissection at ostium of RCA. The dissection most likely was cause by trauma from guiding catheter. Decision made to cover the dissection with a stent. A self-apposing stent of Stentys 3.5-4.5 x17mm deployed at the ostium. After removal of the stent noted the stent has migrated. The trapped wire was rewired over the stent into the RCA. An Amplatz goose snare 25mm used to snare the stent. The stent was snare midway and lock into the guiding catheter. The whole system was pulled en-block to the radial sheath to be removed. Due to the large and distorted stent it was not able to pull out of the radial artery. We have to resort to leaving it in-situ and refer to vascular surgeon for removal. Nichiban and pressure bandage applied. Proceed to right femoral artery puncture. 6Fr Sheath JR4 used to engage the RCA. The Ostial dissection had extended to mid-segment. BMW wire was passed distally. Predilatation with SC balloon 3.0 x 15mm. 2 Overlapping stent of 3.5 x 38 and 4.0 x 34mm deployed. Post-dilatation with NC balloon 4.5mm. Patient hemodynamic stable throughout procedure. No chest pain. After the procedure he was observed in CCU. The perfusion to the right hand was preserved. The vascular surgeon manage to remove the dislodged stent under local anaesthesia. He made good recovery and manage to discharge home after 4 days of admission. Stage PCI to LAD/LCx on later dates.
Presentation Time: 1637- 1652
Dr. Tan Chen Ting (1), Dr Khiew Ning Zan (1
BUY ONE “FREE ONE”
Tan Chen Ting
Sarawak Heart Centre
Asia CC Complication Case
Summary and Introduction
74-year old gentleman with cardiovascular disease risk factors of hypertension and dyslipidaemia. He has underlying double vessel disease on medical therapy in view of the difficult vascular access and patient refused CABG. He presented with recurrent NSTEMI and echo showed worsening EF. He was planned for elective COROS +-PCI after heart team discussion. Coronary angiogram was performed on 28 of November 2017, showed subtotal occlusion in the LAD mid-segment and 50% diseased in the proximal segment of RCA, 80% stenosis in the proximal PDA. Decided for PCI to mid LAD. Radial approach with 6F XB. A 0.014-inch PT guide wire was introduced into distal LAD.
The lesion was pre-dilated sequentially from distal to mid LAD with a 2.0x12mm Emerge NC balloon up to 24atm. Post dilatation noted a perforation in the distal LAD. Present of persistent leakage even with the prolonged inflation of same 2.0x 12mm NC balloon at 18atm for up to 30 minutes. Subsequently, right femoral artery punctured done and using JR4 5 FR guiding catheter engaged to RCA. No bleeding from the collateral LAD. A 2.5x 20mm papyrus covered stent was deployed to 8atm and overlapping with a 2.75x18mm Xience Xpedition DES proximally to 14atm. The bedside echocardiogram demonstrated 2 cm pericardial effusion at the RA/RV and inferior wall. Percutaneous pericardiacentesis was successfully performed with 350ml fresh blood tapped out. Pericardial drainage catheter was keep in situ.
Patient was subsequently observed and transfused 1 pint packed cell in CCU. 2 hours later, patient complained of chest pain and BP dropped. Started inotropic support and repeated bedside echocardiogram noted massive pericardial effusion with tamponade. Pericardial aspiration done, 1200ml fresh blood aspirated and cath lab was activated. Unfortunately, patient condition deteriorated and succumb 4 hours later.
Risk factors for coronary perforation. Clinical versus technique-associated factors.
What to do when coronary artery perforation?
Double perforation of coronary artery is a rare and it is potentially fatal as a result in life threatening cardiac tamponade. Management of coronary perforation requires early detection and angiographic classification. Caution is needed while advancing guide wires and dilating the coronary lesion either pre-stent, during or post-stent implantation.
Presentation Time: 1653- 1708
Khaw Chee Sin (1), Voon Chi Yen (1), Khiew Ning Zan (1), Ong Tiong Kiam (1)
THE CHALLENGES OF A POPPING BALLOON
Khaw Chee Sin
Penang Heart Hospital
Asia CC Complication Case
This is a case of stent balloon ruptured during stent deployment.
1. Discuss on strategies to deal with a partially deployed stent
2. Illustration on ways to assist re-deployment of a partially expanded stent
Description of the problem
66 years old gentlemen, ex smoker, dyslipidemia. Presented with NSTEMI, TIMI score 3. Coronary angiogram revealed moderate disease LAD and subtotal occlusion proximal RCA, both lesion appeared calcified. Proceeded with ad hoc PCI of RCA lesion. During DES deployment, the stent balloon ruptured. The DES migrated proximally and the stent was left half deployed. During retrieval of the rupture balloon, both the guiding catheter and coronary wire was pulled out from coronary artery.
Procedure, technique and equipment's used + results
Careful re-wire and a pre dilatation balloon was used to ensure the wire is inside the stent strut to avoid entanglement in the struts. After successful re-wire, a lower profile balloon was used to facilitate subsequent larger balloon entry. Advance partially through the stent, and open it partly, remainder of the stent can be expanded sequentially. Eventually, manage to successfully re-deploy the DES.
Presentation Time: 1709-1724
Dr Foo Yoke Loong (1), Dr Kamaraj Selvaraj (1), Dr Asri Ranga (1), Dr Abdul Muizz, Dr Abdul Kahar
THE ILIAC WITH MULTIPLE HOLES
Foo Yoke Loong
University Putra Malaysia
Interesting PCI Case: Best of Malaysia
55 year old gentleman with history of Diabetes, Hypertension and IHD with history of CABG in 1998. Presented to us with recurrent chest pain. During coronary angiogram and graft study, there was a CTO right iliac with moderate stenosis at ostial left iliac. Angiogram and graft study was continued via left femoral.
Patient was electively admitted for PCI to CTO right iliac up till ostium. For CTO iliac intervention our option are antegrade or retrograde access. As it was a ostial CTO we believe the antegrade option was more challenging with poor guiding support and difficulty in placing an ostial stent. We decided to try with retrograde attempt to cross the CTO with Right Femoral Puncture with 6F sheath and if we fail will change to antegrade CTO crossing. Terumo wire easily crossed the CTO without support catheter and confirmed with contralateral injection. As left ostial iliac have moderate stenosis we decided to do a direct V stenting on both iliac with balloon expandable stent 8.0x29mm left and 8.0x59mm right. Post stenting we predilate the left iliac with 7.0x100mm and patient complaint of pain during predilation of mid iliac.
Angiogram showed severe perforation just before the first stent. Immediately we balloon the perforated area with the 7.0x100mm balloon and 12.0x60mm balloon at aorta to achieve adequate tampoande. Covered stent with 7.0x59mm and post dilated with 8.0x29 balloon to provide adequate seal. Another perforation at distal to covered stent and stented with 10.0x59mm covered stent. After this there was another perforation at proximal to stented area while removing balloon and stented with 6.0x59 covered stent. Again we have another perforation proximal to the covered stent. We have finished our cover stent in the hospital and called out supplier for emergency stent. Continuous ballooning at perforation and distal aorta was done while waiting for stent. Finally covered stent the final perforation with 6.0x59. In total there was 4 perforation with 4 covered stent
Iliac perforation is a medical emergency and carries high mortality. Covered stent is essential, reversal of heparin and balloon tamponed at perforation site and distal aorta can reduce bleeding.