P.O. Box 2925 Riyadh – 11461KSATel: +966 1 2520088 ext 40151Fax: +966 1 2520718Email: sha@sha.org.saURL: www.sha.org.sa

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Disclosure: Author has nothing to disclose with regard to commercialsupport.

Received 30 January 2015; revised 2 February 2015; accepted 9 February2015.Available online 17 February 2015

⇑ Corresponding author at: Via Antonello da Messina 75, Acicastello,95021 Catania, Italy. Tel.: +39 095 7263122; fax: +39 095 7263124.

E-mail address: argalassi@gmail.com (A.R. Galassi).

1016–7315 � 2015 The Authors. Production and hosting by Elsevier B.V. on behalf of King Saud University. This is an open access article under the CC BY-

Coronary perforation with tamponadesuccessfully managed by retrogradeand antegrade coil embolization

NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Peer review under responsibility of King Saud University.

URL: www.ksu.edu.sa

http://dx.doi.org/10.1016/j.jsha.2015.02.005 Production and hosting by Elsevier

Marouane Boukhris a,b, Salvatore Davide Tomasello a, Salvatore Azzarelli a,Zied Ibn Elhadj b, Francesco Marzà a, Alfredo Ruggero Galassi a,⇑

a Department of Medical Sciences and Pediatrics, Catheterization Laboratory and Cardiovascular Interventional Unit,Division of Cardiology, Cannizzaro Hospital, 95021 Cataniab Faculty of Medicine of Tunis, University of Tunis El Manar

a Italyb Tunisia

In recent years, retrograde approach for chronic total occlusions has rapidly evolved, enabling a higher rate ofrevascularization success. Compared to septal channels, epicardial collaterals tend to be more tortuous, more difficult tonegotiate, and more prone to rupture. Coronary perforation is a rare but potentially life-threatening complication ofcoronary angioplasty, often leading to emergency cardiac surgery. We report a case of a retrograde chronic totalocclusion revascularization through epicardial collaterals, complicated by both retrograde and antegrade coronaryperforation with tamponade, and successfully managed by coil embolization.

� 2015 The Authors. Production and hosting by Elsevier B.V. on behalf of King Saud University. This is an openaccess article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Keywords: Chronic total occlusion, Percutaneous coronary intervention, Coronary perforation, Tamponade, Coilembolization

Introduction

The prognostic benefits of chronic total occlu-sion (CTO) revascularization are well-

recognized today [1,2]. However, despite thedevelopment of equipment and techniques [3],CTO percutaneous coronary intervention (PCI)remains challenging, with a lower success rateand a higher rate of periprocedural complicationsthan non-CTO lesions [4]. The retrograde

approach, particularly via septal channels, canimprove recanalization success rates. Althoughepicardial collaterals in experienced hands mayalso represent an efficient option, their use is asso-ciated with a higher risk of complications [5].

Coronary perforation is a rare, but potentiallylife-threatening complication of PCI, with an inci-dence ranging from 0.1% to 0.5% [6]. As the con-ventional treatment of such a complication,

Abbreviations

CTO chronic total occlusionD1 first diagonalDES drug-eluting stentIABP intra-aortic balloon pumpLAD left anterior descendingLCx left circumflexPCI percutaneous coronary interventionRCA right coronary artery

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consisting of reversal of anticoagulation and pro-longed balloon inflation, is associated with highrates of death, myocardial infarction and needfor emergency surgery, other strategies such ascovered stent use and coil embolization haverecently emerged, showing better outcomes [7].

We report a retrograde CTO revascularizationcase through epicardial collaterals complicatedby perforation with tamponade and successfullymanaged by both retrograde and antegrade coilembolization.

Case report

An 84-year-old ex-smoker and dyslipidemicmale, with a history of pacemaker implantationfor third degree atrioventricular block, was admit-ted for cardiogenic shock one hour after chestpain onset. The electrocardiogram showed an STdepression in lateral leads with Q wave inantero-septal leads. The 2-D echocardiogram

Figure 1. Coronary angiography. (A) Right caudal view showing a thrombCTO of LAD. (B) Left caudal view after DES implantation in proximal LCshowing the LAD CTO with side branch at the proximal cap and blunt stumsecond segment of a minor right RCA. Abbreviations: CTO = chronic totalLCx = left circumflex; RCA = right coronary artery; PCI = percutaneous cor

revealed an impaired left ejection fraction (35%)with a global hypokinesia. A coronary angiogra-phy was performed with intra-aortic balloonpump (IABP) support showing a sub-occlusionof proximal dominant left circumflex (LCx)(Fig. 1A), a proximal occlusion of left anteriordescending (LAD) and a tight stenosis of the sec-ond segment of a minor right coronary artery(RCA) giving septal and epicardial collaterals toLAD (Fig. 1). According to the clinical setting,

otic sub-occlusion of proximal dominant LCx (arrow), and a proximalx with good angiographic result. (C) Right cranial view after LCx PCIp. (D) Left anterior oblique view showing a tight stenosis (arrow) of theocclusion; DES = drug eluting stent; LAD = left anterior descending;onary intervention. The star shows the proximal cap of LAD CTO.

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electrocardiogram modifications and the presenceof retrograde filling of LAD by collaterals fromRCA, LCx was considered to be the culprit vesselwith a CTO of LAD. PCI of LCx was performedand a drug-eluting stent (DES) was implantedwith a good angiographic result, while antegradeapproach for LAD CTO was unsuccessfullyattempted by a non-CTO operator. The in-hospital stay was uneventful and the patient wasdischarged after seven days. Two months later,a myocardial scintigraphy revealed viablemyocardium in the anterior territory, and thepatient was admitted for a second attempt torevascularize LAD CTO by a dedicated CTOoperator.

A double 7-Fr femoral access was performed. A7-Fr EBU 4 (Cordis Co., USA) was introduced inthe left main, while a 7-Fr Amplatz-left 2 (CordisCo., USA) was employed for RCA. The patientreceived 5000 UI of unfractionated heparin andan IABP support was used. Bilateral simultaneousinjection showed a contralateral retrograde fillingof LAD from tortuous screw-like epicardial CC2(Werner’s Classification) [8] and septal collateralCC1, originating from RCA (Fig. 2). Because ofthe presence of a side branch at the proximalcap with a blunt stump, a retrograde approachwas selected as the initial strategy.

Figure 2. Bilateral injection showing a retrograde filling distal LADfrom tortuous screw-like contralateral epicardial collaterals CC2(Werner’s classification) [8], and septal collaterals CC1, originatingfrom RCA. Abbreviations: LAD = left anterior descending; RCA =right coronary artery.

PCI of RCA with one DES implantation was firstperformed (Fig. 3A). A retrograde Sion guidewire(Asahi Intecc Co., Japan) and Corsair micro-catheter (Asahi Intecc Co., Japan) were used(Fig. 3B), reaching the distal true lumen of LADvia the epicardial collateral. Then, Ultimate Bros(Asahi Intecc Co., Japan) guidewire was able tomake a retrograde crossing of the lesion. Theexternalization was performed with RG3 guide-wire (Asahi Intecc Co., Japan) (Fig. 3C). Afterpre-dilation, a DES was implanted in mid LADthrough the retrograde guidewire, while the DESimplantation in the median segment of first diag-onal was performed through an antegrade Run-through (Terumo Corp, Japan) guidewire.Thereafter, the retrograde LAD guidewire andthe Corsair were retrieved, and an antegrade Run-through guidewire was inserted in LAD to prop-erly treat LAD-D1 bifurcation.

Shortly afterwards, the patient showed sud-den hypotension and dyspnea. Immediate rightangiogram revealed an extravasation of contrastmaterial at the distal end of the epicardial col-lateral (Fig. 3E), and an echocardiogram showeda massive pericardial effusion with tamponade.A pericardiocentesis was performed, yielding700 ml of blood auto-transfused thereafter viafemoral venous catheter. A first AXIUM Detach-able Coil (ev3, USA) 2.0 � 2.0 mm was deliveredretrograde through FineCross microcatheter(Terumo Corp, Japan), and implanted distallyin the epicardial collateral (Fig. 4A). Since theextravasation of contrast medium to the peri-cardium persisted (Fig. 4B), two supplementarycoils (3.0 � 4.0 mm and 3.0 � 6.0 mm, respec-tively) were implanted more distally. Theabsence of retrograde extravasation was con-firmed in repeat angiograms (Fig. 4C). Pro-tamine (2.5 mg) was then administered. As thepatient showed hemodynamic stability, wedecided to complete the LAD revascularization.A double kissing crush technique wasemployed to treat the LAD-D1 bifurcation. Atthe end of the procedure, the pericardial drai-nage was productive again, and left angiogramrevealed an extravasation of contrast at thejunction of distal LAD and epicardial collateral(Fig. 5A). Two coils (3.0 � 6.0 mm and3.0 � 4.0 mm, respectively) were thereforeimplanted antegrade (Fig. 5B). Final right andleft angiograms confirmed the absence of resid-ual extravasation (Fig. 5C). The in-hospital staywas uneventful and the patient was dischargedafter eight days. At five-month follow-up, hewas asymptomatic.

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Figure 3. (A) Angiographic result after DES (2.25 � 14 mm) implantation in RCA. (B) Retrograde Sion guidewire and Corsair in tortuous screw-like epicardial collateral. (C) Successful externalization of retrograde RG3 guidewire (Asahi Intecc Co., Japan). (D) Left angiogram after DESimplantation in mid LAD through the retrograde guidewire, and in mid-D1through an antegrade guidewire. (E) Right angiogram showingextravasation of contrast media at the distal end of the epicardial collateral, after the removal of retrograde guidewire and insertion of anantegrade guidewire in LAD. Abbreviations: D1 = first diagonal; DES = drug eluting stent; RCA = right coronary artery. The letter « M » showedthe radio-opaque tip of the microcatheter.

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Discussion

Over the past few years, the retrogradeapproach for CTO lesions has rapidly evolved,enabling a higher rate of revascularization suc-cess. The tortuosity of the collateral channelremains one of the biggest contributors of difficul-ties and procedural risks. The use of a dedicatedmicrocatheter such as Corsair, with a moremaneuverable structure, allows the guidewire toadvance with ease.

Compared to septal channels, epicardial collat-erals (particularly from RCA) tend to be more tor-tuous with potentially inelastic stenosis.Epicardial collaterals are therefore more difficultto negotiate and are prone to rupture whendilated. Moreover, in contrast to intramyocardialchannel ruptures resulting in no major complica-tions, epicardial collateral channel ruptures oftenlead to tamponade [5].

Coronary perforation is a rare but serious com-plication occurring in 0.1–0.5% of patients under-

going PCI [6], with a relatively high mortalityrate ranging from 7 to 17% [7]. It represents oneof the most frequent complications experiencedby patients undergoing CTO recanalization proce-dures, and its rate is higher in retrograde than inantegrade approach [4].

Guidewires are a major cause of coronary perfo-rations, particularly those with hydrophilic-coating commonly used in CTO procedures. Bal-loon ruptures and the use of rotablators for calci-fied lesions are the other common etiologies ofthis complication [6,7].

In our patient, the retrograde perforation couldhave been caused by the advance of the hydrophi-lic guidewire and/or microcatheter maneuver inseverely tortuous epicardial collateral. Initiallysealed by the retrograde guidewire, the perfora-tion became patent after its removal and replace-ment by an antegrade guidewire in LAD. On theother hand, the antegrade delayed perforationmight have been due to the intensity of antegradecontrast injection in the ‘fragile,’ damaged

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Figure 4. (A) First retrograde coil delivery AXIUM Detachable Coil (2.0 � 2.0 mm) through FineCross microcatheter in the epicardial collateral.(B) Selective injection showing persistence of contrast extravasation after first coil embolization. (C) Absence of contrast extravasation after 2supplementary retrograde coils implantation (3.0 � 4.0 mm and 3.0 � 6.0 mm). The letter « M » showed the radio-opaque tip of themicrocatheter.

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junction between LAD and epicardial collateraloriginating from RCA. This fact underscores theimportance of checking the collateral used for ret-rograde approach by bilateral injections.

The treatment of coronary artery perforationrequires a multipronged approach: treating theperforation, maintaining hemodynamic stabilitywith pericardiocentesis and/or with IABP, andreversing the effects of antithrombotic therapy.The treatment options of the perforation mostcommonly used include low-pressure balloondilation, implantation of covered stents, coil andmicrosphere embolization, and emergency cardiacsurgery [6,7].

The AXIUM Detachable Coils (ev3, USA) consistof a platinum coil attached to a composite implantdelivery pusher with a radiopaque positioningmarker and a hand-held instant detacher which,when activated, detaches the coil from the deliv-ery pusher tip. The design of an embolization coilinvolves a wire (usually of steel or platinum) thatis wound tightly into a straight primary coil, and

then formed into a secondary structure of variousdesigns such as helices in our case. Regarding themanufacturer, the coil delivery to the site of perfo-ration may require a microcatheter, as observed inour case. Coil implantation induces thrombosis,leading ultimately to fibrosis. To reverse heparineffects, protamine should be administered aftercoil distal delivery to avoid proximal thrombosis,or, better yet, after complete sealing of the perfo-ration. Once the coil is delivered, a small selectivedistal injection from the microcatheter tip can beperformed to detect residual extravasation,requiring further coil embolization.

First invented for the endovascular embolizationof intra-cranial aneurysms, fistulas, pseudoa-neurysms and other neurovascular abnormalities,coil embolization has been successfully employedin cases of distal coronary perforation [9,10].

To the best of our knowledge, this is the firstreported case of a CTO procedure complicatedby coronary perforation with tamponade, andmanaged by both retrograde and antegrade coil

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Figure 5. (A) Left angiogram showing contrast extravasation at the junction of distal LAD and epicardial collateral. (B) Antegrade delivery of 2coils (3.0 � 6.0 mm and 3.0 � 4.0 mm) in epicardial channel. (C) Angiographic success of LAD CTO recanalization and absence of contrastextravasation. Abbreviations: CTO = chronic total occlusion; LAD = left anterior descending; TIMI = Thrombolysis in myocardial infarction. Theletter « M » showed the radio-opaque tip of the microcatheter.

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embolization. Coils might represent useful tools inthe armamentarium of interventional cardiolo-gists, particularly those performing CTO proce-dures, and may help in forestalling emergentcardiac surgery for coronary perforations.

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