The Detrimental Impact of Chronic Renal Insufficiency

Alfredo R. Galassi MD, FESC, FACC, FSCAIDirector of Cardiac Catheterization and Interventional Cardiology Unit

Department of Medical Sciences and PediatricsDivision of Cardiology, Cannizzaro Hospital, University of Catania, Italy

A Septal Perforation: The Best Of The Worst

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CASE SUMMARY Clinical PresentationExertional angina (CCSC II)and dyspnea (NYHA II)Patient: C-C, male, 59 yrs Risk FactorsHypertension DyslipidemiaCoronary AngiographyMid LAD CTONon-invasive Testing2D Echo: Hypokinesia in anterior territory, EF 50%

Coronary Angiography

Target lesion: LAD

Antegrade Failed AttemptTarget lesion: LAD

Collaterals

Target lesion: LAD

Septal channels

Sion Asahi InteccTarget lesion: LAD

Sion advancing through septal channelsSion Asahi InteccTarget lesion: LAD

Externalization

RG 3 Asahi IntecTrapping balloon

Stent Implantation2 DESCre8 3.0x31 mm; Cre8 2.75x31mm

Final Result (time: 2.0 pm oclock)Total procedural time = 18 min

After Corsair withdrawing

After Corsair withdrawingSeptal perforation

7 min later Tachycardia and hypotension

Septal fenestration and pericadial effusionTTE showed tamponade

Pericardiocentesis

Antegrade coil implantation

Retrograde coil implantation

Persistance of extravasationSecond retrograde coil implantation

Further retrograde coil implantation in posterior descending artery

Absence of right ventricular perforation

Final ResultStable hemodynamic status HR 90 bpm; systolic pressure 110 mmHgThus, protamin was administered (35 mg)

1 hour later tachicardia and hypotension suddenly developedPatiient was brought back to cath lab (time: 9.00 oclock)

TTE showedsudden increase in pericardium effusion and tamponadeAngio revelaed again active bleeding in pericardium from septal fenestration

Further antegrade quick coil implantation (no heparin infusion)

Because protamine administration and long-standing procedure pericardiocentesis drainage became difficult due to catheter clotting

Final Result (no active bleeding)

TTE confirmed clots in the pericardium with signs of compression with unproductive drainage

Because of the incoming night and the unproductive drainage it was decided to transfer the patient for surgical pericardium assessment

Cardio-thoracic chest opening was performed after 10 hrs (time: 00.00 am oclock)

No active bleeding in the pericardium was observed, finally stopped! Surgical drainage of clots was performed

OutcomePatient was discharged 1 week laterTwo-month follow-up was uneventfulHe is running daily working activity

Take Home Messages Septal channels represent reliable and relative safe collaterals to achieve successful retrograde CTO revascularization

Septal perforation is very often benign but not always; septal collateral fenestration might be dangerous

Coils are important tools in the armamentarium of CTO operators (they achieve perforation closure with no significant flow impairment in the main vessel)

Emergency cardiac surgery should be considered in rare cases