Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Mohan Z Mani

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Dr Mohan Z Mani,
Professor & Head,
Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Reviews
Year : 2021 | Month : July | Volume : 15 | Issue : 7 | Page : OE01 - OE05 Full Version

Coronary Perforation-A Nightmare in Cath Lab


Published: July 1, 2021 | DOI: https://doi.org/10.7860/JCDR/2021/46554.15170
Ashok Kumar Thakur, Puneet Aggarwal, Rajeev Bharadwaj, Bhagya Narayan Pandit, Ranjit Kumar Nath

1. Senior Resident, Department of Cardiology, ABVIMS and Dr RML Hospital, New Delhi, India. 2. Assistant Professor, Department of Cardiology, ABVIMS and Dr RML Hospital, New Delhi, India. 3. Senior Resident, Department of Cardiology, ABVIMS and Dr RML Hospital, New Delhi, India. 4. Associate Professor, Department of Cardiology, ABVIMS and Dr RML Hospital, New Delhi, India. 5. Professor and Head, Department of Cardiology, ABVIMS and Dr RML Hospital, New Delhi, India.

Correspondence Address :
Dr. Bhagya Narayan Pandit,
11/19, Upper Ground Floor, Old Rajender Nagar, New Delhi, India.
E-mail : bnpandit1977@gmail.com

Abstract

Percutaneous Coronary Intervention (PCI) is now the standard of care in patients with coronary artery disease. With advances in modern technology, the success of PCI has relatively increased, and so is its complication, specifically in complex coronary intervention. Coronary perforation is one of the most dreadful and life-threatening complications of PCI. The most vital step in the management of coronary perforation is its identification and quick action. Multiple methods for management are now recommended in the literature, but the mainstay of treatment is still prevention. This review discusses the incidence, risk factors, prevention, identification, and management of Coronary Artery Perforation (CAP).

Keywords

Ellis classification, Guidewire, Percutaneous coronary intervention

Percutaneous Transluminal Coronary Angioplasty (PTCA), also known as PCI, is a minimally invasive process to open coronary artery stenosis or open blocked blood flow to the myocardium. Deposition of lipid-rich plaque within the arteries causes coronary stenosis leading to decreased coronary blood flow to the myocardium. CAP is a potentially fatal complication of PTCA. The vital step in the management of CAP is prompt identification and quick action. Although management varies with the type of perforation, a universal initial treatment approach can be followed. Risk of occurrence of CAP can be significantly reduced by carefully selecting the guidewire and baloon that is of an appropriate size. Intravenous anticoagulants need to be discontinued immediately. Activated clotting time should be measured and corrected with protamine. Management may vary as per the patient’s haemodynamic status, type of perforation, and availability of resources in cardiac catheterisation laboratories.

INCIDENCE AND MORTALITY

CAP essentially involves an outward incision through the wall of the coronary artery. This becomes evident on fluoroscopy as an extravascular accumulation of the contrast dye used. CAP can range from a slight staining of the myocardium to more serious conditions, such as the rupture of a vessel. CAP complicates 0.1-0.6% of PTCA (1),(2),(3),(4). Its incidence is more (0.5-3%) in procedures requiring bulky athero-ablative devices like rotational atherectomy, transluminal extraction coronary atherectomy, directional atherectomy, or excimer laser angioplasty (5),(6),(7),(8).

With the increasing boldness of the modern interventionalist, with increasing frequencies of complex coronaries and Chronic Total Occlusions (CTOs) being performed in the catheterization laboratory (cath lab), recent trends indicate a rise in CAP’s incidence.

The overall in-hospital mortality rate in CAP is 16.7% (9). Thus, the rapid recognition of CAP is essential to employ life-saving management techniques promptly. A 19-28% of CAP causes cardiac tamponade and has to be managed aggressively with pericardiocentesis, while the majority of CAP can be managed conservatively (10),(11). The incidence of pericardial tamponade and mortality adhered to the classification by Ellis (1), For example, type I-0.4% and 0.3%; type II-3.3% and 0.4%; type III-45.7% and 21.2%, respectively. It has also been observed that the occurrence of serious cardiac events are linked to type II CAP, which can occur over a prolonged period of time (10). It has also been observed that 14.8% of deaths among hospitalised patients are associated with type III CAP as per Ellis classification (10). Close observation with serial echocardiography and intensive cardiac monitoring is strongly advised postoperatively as small leaks caused by a guidewire or any late tear extension can lead to cardiac tamponade and sudden deterioration of the patient even up to 48 hours later (12).

CLASSIFICATION OF CORONARY ARTERY PERFORATION (CAP)

Ellis classification (1) is the most popular and widely used classification for CAP as shown in (Table/Fig 1), (Table/Fig 2), (Table/Fig 3) (Table/Fig 4).

Type II and III CAP can result in life-threatening complications. Out of 12900 procedures conducted by Ellis SG et al., (1), it was observed that Type I CAP caused cardiac tamponade in 8% and no deaths or Myocardial Infarction (MI); Type II CAP caused cardiac tamponade in 13% and MI in 14%; Type III CAP caused cardiac tamponade in 63% and mortality in 19%.

RISK FACTORS FOR CORONARY PERFORATION

(A) Non Modifiable Risk Factors:

Elderly patients and patients with previous CABG or past procedures involving the coronary arteries have increased propensity to develop CAP (13). Some other minor factors that increase the risk of developing CAP include a history of congestive heart failure, hypertension, diabetes mellitus, females sex, and chronic kidney disease (14).
(B) Modifiable Risk Factors:

(i) Angiographic characteristics:

Complex angiographic characters like type B or type C lesion (8), (CTO) arteries (8),(15), calcified lesion (8),(15), tortuous, and angulated lesions increase the risk of CAP. In small coronary size, especially in right coronary or circumflex arteries, or the presence of multivessel coronary disease, PCI is associated with higher CAP.

(ii) Use of atheroablative devices:

Ellis SG et al.. found a higher incidence of CAP with devices that removed rather than displaced tissue (1). CAP rates were 1.3% following the removal of atheroma from the lumen of the coronary arteries and 2% following coronary angioplasty using a laser. Lloyd-Jones D et al., reported an incidence of CAP of 3% (16), while Ajluni SC et al., reported CAP in 0.39% of patients using excimer laser in coronary angioplasty (5). Class III CAP is more likely to develop in the procedures where instruments that remove atheromatous plaque are used. The increased occurrence of CAP has been linked to procedural training using these instruments. However, development of CAP can be prevented by using steeply angulated segments with a burr size of <0.8 (10).

(iii) Hydrophilic wires:

Hydrophilic wires have equipped cardiac surgeons with a crucial tool to effectively treat CTO and other complications associated with coronary artery damage. In a study by Javaid A and Kiernan TJ et al., it was reported that using hydrophilic guidewires were responsible for 65%-87% of CAP cases (9), (15); however other studies have reported conflicting data (17) so, it is still a matter of debate if CAP is actually caused by the use of hydrophilic guidewires or it is just perceived that the higher incidence of CAP arises from their increased use.

(iv) Balloon angioplasty and stents:

Although wires cause most CAPs, CAP is less frequently caused by balloons or stents. CAP can arise from inserting stents into severely damaged coronary arteries, inflating the balloon under high pressure, using large-sized balloons, and using balloons that do not comply with the specified procedural criteria. In fact, balloons and stents are responsible for 0.05% to 0.15% of CAP incidence during procedures involving PCI (5),(6),(7),(8),(9),(10),(11),(12),(13),(14),(15),(16),(17),(18),(19). A balloon to artery ratio of >1:1 is linked to a two to three-fold rise in the incidence of CAP (5). During inflation, rupture of the balloon predisposes to perforation of the artery by production of pin-hole orifices, due to the jet under high pressur.

(v) Use of adjunctive anti-thrombotic therapy:

There have been conflicting reports between the possible association of the use of anti-thrombotic therapies like glycoprotein (GP) IIb/IIIa inhibitors and the incidence, severity, and outcomes of CAP.

In Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction (HORIZONS-AMI), therapy of CAP patients using antithrombotics, such as bivalirudin, didn’t worsen the prognosis, compared to heparin plus GPIIb/IIIa inhibitors (11),(12). It has been reported by Ramana RK et al., that using GPIIb/IIIa inhibitors didn’t disturb the hemodynamic condition of CAP patients (19). In a series of 39 CAP cases, Witzke et al., reported that the use of GPIIb/IIIa didn’t influence the outcome (20). It has also been reported in a group of 6214 patients (of whom 39 had CAP), that adjunctive therapy with abciximab neither elevated the risk of CAP, nor had any adverse effects on the clinical prognosis of patients already suffering from CAP (4).

It has been reported by Gunning MG et al., that pericardial drainage was needed in 9 out of 10 CAP patients who were on GP IIb/IIIa inhibitors. Moreover, in 4 of these CAP patients, signs of tamponade were observed over two hours following PCI (21). In these 4 cases, it was presumed that the underlying cause of the tamponade was due to puncturing of the coronary arteries by a guidewire, resulting in bleeding, which was aggravated by GPIIb/IIIa inhibitors. It was reported by Fasseas P et al., that in 33.3% of CAP patients on GPIIb/IIIa inhibitors, there was a need for placement of covered stent or emergency heart surgery, compared to 3.2% of patients who didn’t (12). However, the type of perforation and clinical prognosis, including tamponade, MI, and death, between the two groups were the same. A study by Stankovic G et al., found that there was a higher incidence of CAP with the concurrent use of GPIIb/IIIa inhibitors (13). In another study by Kini AS et al., it was observed that tamponade arising from guidewire-related CAP, occurred less frequently when bivalirudin was used, compared to heparin due to its reversibility and shorter half-life (22).

Sequel of coronary artery perforation (CAP)

CAP can lead to distal ischaemia, blood loss, cardiac tamponade, cardiogenic shock, and death. Even the management strategy can cause myocardial ischaemia by acute vessel closure or may require immediate surgery, adding morbidity and mortality

DIAGNOSIS

Besides the typical symptoms associated with inflation of the balloon, there may be some atypical symptoms, including nausea, vertigo, and severe chest pain. Following deflation of the balloon, there may be persistence of the ST-T changes. Vasovagal attack might also occur perforation, along with slow heart-rate (bradycardia) and low blood pressure (hypotension). In these instances, a high-degree of suspicion is a prerequisite for the timely detection of even a minute perforation caused by a guidewire, which may otherwise result in pericardial tamponade being delayed. There may be abnormal migration of wire tip. Once the perforation occurs, the key step is to remain calm and call for additional help.

PREVENTION AND MANAGEMENT OF CAP

Prevention of Perforation

The best way to manage a CAP is to prevent it. Morphologic assessment of complex lesions should be done by Intravascular Ultrasound (IVUS) (to analyse location, depth, and eccentricity of calcification). Unfractionated Heparin (UFH) is preferred in long procedures as it is easily reversible, and adjuvant anti thrombotic like GP IIb/IIIa inhibitors should be used with keeping a watch on optimal Activated Clotting Time (ACT). Final angiograms in multiple views should be seen with dual injections and delayed views in suspected cases.

Meticulous attention to the following steps during angioplasty is a must:

• Guidewire advancement and positioning: Resistance to guidewire advancement, buckling of the wire, or restricted tip movements of wire should be exercised with caution as the wire may be subintimal. In such cases, withdraw and reposition the wire. If in doubt, a gentle dilute contrast injection can be delivered through a microcatheter or the central lumen of an Over-The-Wire (OTW) balloon after removing the wire. Persistent contrast staining indicates a position within a false lumen, indicating the need to reposition the wire.
• Balloon choice: Noncompliant balloons should be used for postdilatations and for high-pressure balloon dilatations in nonyielding lesions.

Device sizing: Only in case of PTCA, a balloon-to-artery ratio of 1.0 and device-to-artery ratio of 0.5-0.6 in case of lasers and rotablaters, should be used. Always appropriately pretreat a calcified lesion with rotational atherectomy rather than aggressively trying to postdilate with an oversized noncompliant balloon to expand an under-expanded stent optimally.

Stent-related perforations can be avoided by appropriate stent position. When the distal part of the dissection can be ascertained by angiography, only then stents should be used.

Management

The strategy for management of perforation has to be individualised and depends on the site of perforation, the severity of insult, persistent leak, and haemodynamic stability of the patient.

Supportive therapy includes O2, Intravenous (IV) fluids, analgesia/sedation, atropine for bradycardia, inotropic support and/or Intra-aortic balloon pump for hypotension

The most vital step in management is prompt identification and quick action. Although management varies with the type of perforation, a universal initial treatment approach can be followed. Valuable time may be gained by prolonging inflation of the balloon proximally (1:1 balloon: vessel size). However, it should be kept in mind that distal ischaemia can occur if balloon dilation is prolonged. This is especially so when downstream collaterals are absent. In contrast, the perforation can be sealed by perfusion balloons, at the same time as distal vessel perfusion. Intravenous anticoagulant and antiplatelet therapy should be stopped and reversed immediately. Activated clotting time needs to be estimated, following which, protamine should be administered to reverse the effects. Moreover, there may be a need for platelet transfusions if GPIIb/IIIa antagonists were used.

Type I CAP

Intermittent injection of contrast dye, accompanied by continuous monitoring is a good approach for minor breaches of the coronary vessels. However, if continuous oozing occurs or if ‘contrast blush’ is prolonged, heparin reversal with protamine may be warranted. Importantly, before shifting the patient to a Cath Lab, a 2D echo should be done, which should be repeated intermittently for 24 hours, following the procedure.

Type II CAP

(a) The action of heparin and GPIIb/IIIa inhibitors may be reversed with protamine and platelet infusions, respectively. Bleeding is usually reduced by gradually reducing the blood pressure in a controlled manner. In case of patients who don’t have hypertension, there is a need to maintain the Mean Arterial Pressure (MAP) at 50-65 mmHg. However, in patients who have hypertension, the MAP should be kept 30% below the baseline value. Over 40% reduction in bleeding has been reported in case of most studies (18),(23).
(b) Balloon occlusion to halt blood flow into the side branch or proximally to the perforation may be needed in case of a side branch perforation. This is possible with hardly any risk of ischaemia. As per standard procedure, low pressure (2-4 atm) is applied for 15-20 minutes. If the site of perforation is a distal main vessel, a balloon occlusion method should be used. If the perforation is more proximal in the main vessel, such as in a balloon-induced perforation, it requires immediate balloon-tamponade at the site. There may be significant ischaemia in the distal arterial bed in case of proximal balloon tamponade. Therefore, in order permit limited flow, there is a need to inflate intermittently with controlled inflation pressures. This type of procedure has been effective in over 50% of patients (10). However, sometimes, it may not be possible to seal the perforation with balloon occlusion and heparin reversal. In such a scenario, artery size and origin may decide the approach.
(c) For a side branch wire perforation in a smaller vessel (<2.5 mm diameter), a persistent leak can be tackled by arterial occlusion with embolic material, including microcoil (24), gel-foam (25) or Polyvinyl Alcohol Particle (PVA) embolisation (26). Trisacryl (acrylic co-polymer), microspheres linked to gelatin, collagen, thrombin, fibrin glue, cyanoacrylate glue, or subcutaneous fat should be considered in order to close the perforation in the distal coronary artery at the cost of a minute infarction. Slightly oversized microcoil (1.5 times more than the caliber of the target vessel) can be deployed with the help of microcatheters in order to seal the site of perforation mediated by their thrombogenic properties (Table/Fig 5). Other less common percutaneous treatment modalities that can be tried are autologous clot injection (27) and subcutaneous tissue injection (28). Comparatively small-sized distal CAP (<1 mm diameter) can be treated more effectively by gel foam embolisation, than by coil embolisation or PVA foam (25). However, there is a need to exercise extreme caution as reflux of embolic gel into the proximal vessel must be averted. It has been observed that PVA foam embolisation results in permanent sealing, whereas gel foam embolisation produces temporary occlusion that reverts back within 3-4 weeks (29),(30).
(d) Persistent leaks in the main vessel (>2.5 mm diameter) are preferably managed using polytetrafluoroethylene (PTFE) coated covered stents. PTFE stents have both advantages and disadvantages. The major advantages are that these stents are inert, easy to deliver, and biocompatible. However, the major disadvantage is that these are difficult to insert into curved segments, often leading to thrombosis and occlusion of the side branches. Recent advancements in science has led to the development of electrospun polyurethane covered stents with better flexibility and deliverability, thereby greatly reducing chances of thrombosis (31),(32),(33).

Type III CAP

Type III CAP is life-threatening events and often horrifying to the primary operator. Extravasation of coronary blood causes the vicious cycle of ischaemia and tamponade physiology. Balloon tamponade at the site of perforation and pericardiocentesis with autoperfusion should be done. Simultaneous fluid resuscitation and inotropic backup are recommended. Precious time can be saved by having a balloon in a catheter, ready for insertion. Prolonged (5-10 min) balloon inflation should be alternated with brief periods of deflation to prevent MI. This type of alternate cycling is capable of slowly sealing the perforation. However, it should be noted that covered stents are usually required for most type III CAPs, which are effective in more than 90% of cases. A ‘double guide catheter technique’ has been developed to save time during balloon deflation. In this procedure, the coronary artery is hooked sub-electively using a 7F guide catheter through second femoral access. The first guidewire is removed, keeping the balloon catheter in place in an inflated state. The balloon is then slowly deflated while the second guiding catheter positioned. The covered stent is placed OTW at the coronary perforation. Once effectively managed, before taking a final check angiogram, it may take a few minutes for stabilisation and to regain haemodynamic balance. In case of all type III CAPs, the CTVS team must be informed, as surgical intervention might be required for closure, although this is usually very rare, as it is needed only when all interventional options have failed.

Use of Polyvinyl Alcohol (PVA) in Coronary Perforation

PVA particles are used for vascular embolisation by an interventional radiologist for embolisation of arteriovenous malformations, lower gastrointestinal bleeding, and even hypervascular tumours (29),(30). PVA particles have a smooth surface and are inert and biocompatible. They come is various sizes, ranging between 45 microns to 1180 microns and are used for occlusion of arteries having small bore. They are prepared in contrast medium and produce dilute suspensions that are slowly infused via the balloon catheter or microcatheter to occlude small vessels. It is important to utilise OTW balloon catheter for PVA particles having a small diameters, usually below 300 microns, which are capable of passing through a lumen of 0.014 inch. Microcatheter can be considered as a carrier when larger sized PVA particles (>300 microns) are used (Table/Fig 6), (Table/Fig 7).

Conclusion

Pre-procedure planning with respect to patient characteristics/lesion is required for prevention.

It is imperative that there is proper awareness of guidewire selection criteria, the various associated risks, and the importance of avoiding balloon overexpansion. The likelihood of distal CAP can be lessened by fluoroscopic monitoring of the distal wire-tip position during balloon catheter exchanges as well as during contrast injection. After wire removal, final angiographic views should profile the distal vascular to detect subtle, delayed contrast extravasation. It is of vital importance that patients are monitored uninterruptedly, both in the cath lab, as well as the Intensive Coronary Care Unit (ICCU), especially in case of high-risk groups.

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DOI and Others

10.7860/JCDR/2021/46554.15170

Date of Submission: Aug 31, 2020
Date of Peer Review: Dec 22, 2020
Date of Acceptance: Jan 22, 2021
Date of Publishing: Jul 01, 2021

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? NA
• Was informed consent obtained from the subjects involved in the study? NA
• For any images presented appropriate consent has been obtained from the subjects. NA

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