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The Nightmare in Cath Lab: Early Identification and Emergent Correct Treatment

The Nightmare in Cath Lab: Early Identification and Emergent Correct Treatment. Yuejin Yang MD, PhD, FACC, FESC Cardiovascular Institute and Fu-Wai Hopital, CAMS & PUMC. The 11th Nanjing Course on Cardiac Revascularization & ACS, in conjunction with CAP-CCBC, Nanjing, Sept. 13, 2013.

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The Nightmare in Cath Lab: Early Identification and Emergent Correct Treatment

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  1. The Nightmare in Cath Lab: Early Identification and Emergent Correct Treatment Yuejin Yang MD, PhD, FACC, FESC Cardiovascular Institute and Fu-Wai Hopital, CAMS & PUMC The 11th Nanjing Course on Cardiac Revascularization & ACS, in conjunction with CAP-CCBC,Nanjing, Sept. 13, 2013

  2. Numbers of PCI in Each Year @ Fu Wai 2011: PCI case No: 10649, Radial 90.8%（9673/10649) TRI from <1% in 1998 to >90% in 2011 with the very low mortality rate of just 0.05% in elective PCI

  3. The Impact of PCI on CHD • Effective in: • Interventional revascularization • Cure the patients with CHD • Safety problems: • Severe complications • Hurt the patients • Even leading to death of the patients • If identification late and treatment • improperly or correctively • Or nightmare in the Cath Lab

  4. Nightmares in Cath Lab ? • Severe PCI complications • Resulting in severe consequences • Even leading to: • death • MI • Emergency CABG

  5. Category of PCI Complications • Coronary • Puncture site • Others • Stent related (BMS, DES) • TRI related • Medication related: • Antiplatelet and anticoagulation • Contrast media • Hypersensitivity (anaphylactic shock) • AKI

  6. Coronary Complications • Coronary injury leading to: • Severe dissection • Acute closure • Rupture • Perforation • Thrombosis • Thrombotic embolism

  7. Access Site Complications • Bleeding • Big hematoma • Post-peritoneal hematoma • A-V fistula • Vessel injury (dissection) • Thrombosis • Thrombo-embolism • Infection

  8. Other Complications • Comorbidities • Systemic thrombo-embolisms • Microvascular embolisms ( thrombosis and air) • Stroke • Brain hemorrhage • GI bleeding • Bleeding on other organs • Vagal reflex and hypotension • Hemodynamic instability

  9. Stent Related Complications • Stent thrombosis • Acute (<24 hrs) • Subacute (1-30 ds) • Late (1-12 ms) • Very late (>1 yr) • Definite • Probable • Possible • Stent dislodge • Stent dystroy

  10. TRI Related Complications • Radial artery closure • Vessel injury by wire and hematoma along with the route • Forearm hematoma and osteo-compartment syndrome • Neck hematoma • Mediastinum hemotoma • Chest hemotoma or pleural bleeding • Stroke • Aortic dissection

  11. Medication Related Complications • Dual antiplatelet and antithrombin therapy • Bleeding ( brain, GI, fundus, gum, et al) • Hemotoma • HIT due to heparin • Plateletcyclopedia due to 2b/3a inhibitor at al • WBC decrease • Hypersensitivity • Contrast media • CKD • Allergy even allergic shock

  12. Clinical Nightmares in Cath Lab • CV collapse • Big coronary (including sidebranch) acute closure • Coronary rupture • Severe no-reflow phenomenon • Cardiac tapenade • Severe allergic shock • Stent thrombosis • Brain hemorrhage • stroke

  13. Case 1: CV Collapse after CAA in Pts with STEMI (IPW) Mr. Zhang Zhengang, M 66 yrs, 810865 STEMI (IPW) for 4 hrs, 2012-6-13 CV collapse after LCA A Bp continually declined before RCA A Continuous CPR, IABP, Intubation preparation IABP pulled out during CPR Left femoral approach to RCA A TIMI flow II with 95% stenosis

  14. Case 1: CV Collapse after CAA in Pts with STEMI (IPW) TIMI flow back to III after 1st aspiration Residual stenosis 90% After 2nd aspiration, residual stenosis 80% No PTCA, No Stent CCU stay for 10 days CABG suggested, but 1-2 Mons later needed Pts discharged on his own demand

  15. Baseline LCA A LAD & LCX CTO Poor local collateral circulation

  16. CPR and RCA A Bp declined before RCAA LFA RCAA under CPR

  17. Final Results • After 2nd aspiration, TIMI flow III • RCA to LAD collateral circulation • Residual stenosis 80% • IABP via LFA • Pts calmed, hemodynamics stable • Sent to CCU

  18. Case 2: Severe Complication – LM dissection leading to acute closure Mr. Song Chen Wu, M 40 yrs, 841948 2013-2-26 XB-LAD Guiding LM dissected and acute closure

  19. Baseline CAA Guiding engaged uncoaxially LM & LAD dissected severely

  20. LAD closure LAD acute closure & IABP support, Wiring Guiding changed to Judkins L3.5

  21. Rescue Successful Wiring successful & ballooning TIMI flow III

  22. Stenting

  23. Final Results

  24. Case 3 RCA Rupture after Post-stent Kissing Mr. Wang Yu min, M 54 yrs, 819648 2012-9-19 Admitted due to ACS

  25. Baseline CAA LAD 80%, Dia 80%, distal LCX 80% Distal RCA & Bifurcation 90%

  26. PTCA and Stenting After PTCA After Stenting （2.75 × 24mm）

  27. Kissing Ballooning 2nd Kissing with high pressure of 12atm 1st Kissing OK

  28. RCA Rupture Balloon occlusion, pericardial centesis, cardiac surgeon consulted RCA Rupture

  29. Covered Stent Covered stent Almost sealed

  30. Final Results ?

  31. 40 Minutes Later Obvious contract media stay in pericardial cavity Massive clot showed in pericardium & stent leakage at distal vessel

  32. Re-sealed Covered stent deployed & leakage sealed with the price of PDA acute closure Another covered stent, JR guiding very deep seating to seal the leakage

  33. Final Results No sign of pericardial effusion

  34. Pericardial Cine Check No sign of pericardial effusion

  35. Case 4: LAD&Dia two stent complicated with ST Mr. Ni Xiang ren, M 45, 819127 2012-8-22 Admitted due to ACS

  36. Baseline CAA Distal RCA 100% with collateral circulation from LAD LAD 90%, big Dia 90%, LCX 90%

  37. Two Stent Strategy Rewiring & Reballooning Kissing ballooning

  38. Final Results OK OK

  39. 3 Hrs Later, Chest Pain with ST Elevation Stent total occlusion due to AST Ballooning

  40. Final Results Flow sluggish without emptying, CV Collapse happened, CPR TIMI Flow OK, LCX 100%

  41. Case 5: Acute Closure of Big RCA Mr. Shang Feng yi, M 56 yrs, 838552 2013-1-13 Big RCA very tortuous Acute closure due to wire injury

  42. Baseline CAA Big RCA very tortuous with tight lesion LAD & LCX OK

  43. RCA Closure and Rescue RCA acute closure due to BMW injury IABP Pilot 50 wiring & ballooning

  44. Stenting Big RCA opened Stenting

  45. Final Results OK, No distal dissection RCA TIMI flow III

  46. Case 6: RCA Stenting Complicating with Side Branches Acute Closure Mrs. Cao Wen hua, F 64 yrs, 782315 2012-1-10 CABG for 5 yrs LAD & LCX 100% RCA In-stent stenosis & occlusion with big side branches

  47. Baseline CAA RCA In-Stent 100% involving two PDA branches LAD & LCX 100%

  48. RCA PCI Ballooning without side branches wire protection Two big branches acute closure

  49. RCA PCI Hemodynamic unstable IABP & Temporary Pacemaker Two side branches TIMI flow I+ One weeks later, Pts died of SCD

  50. Case 7: High risk pts without hemodynamic support Mrs. Zhang Xiu zhen, F 80 yrs, 713486 2010-2-8 Primary PCI for STEMI High risk Pts without hemodynamic support

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