Salvage of Simultaneous Acute Coronary Closure and Retroperitoneal Bleeding Using Veno-Arterial Extracorporeal Membrane Oxygenation and Chronic Total Occlusion Percutaneous Coronary Intervention Techniques in a Patient with ST-Segment Elevation Myocardial Infarction

Salvage of Simultaneous Acute Coronary Closure and Retroperitoneal Bleeding Using Veno-Arterial Extracorporeal Membrane Oxygenation and Chronic Total Occlusion Percutaneous Coronary Intervention Techniques in a Patient with ST-Segment Elevation Myocardial Infarction

CARREV-01538; No of Pages 4 Cardiovascular Revascularization Medicine xxx (xxxx) xxx Contents lists available at ScienceDirect Cardiovascular Revasc...

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CARREV-01538; No of Pages 4 Cardiovascular Revascularization Medicine xxx (xxxx) xxx

Contents lists available at ScienceDirect

Cardiovascular Revascularization Medicine

Salvage of simultaneous acute coronary closure and retroperitoneal bleeding using veno-arterial extracorporeal membrane oxygenation and chronic total occlusion percutaneous coronary intervention techniques in a patient with ST-segment elevation myocardial infarction Iosif Xenogiannis, Katarzyna Hryniewicz, M. Nicholas Burke, Emmanouil S. Brilakis ⁎ Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN, USA

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Article history: Received 17 January 2019 Received in revised form 19 February 2019 Accepted 11 March 2019 Available online xxxx Keywords: Iatrogenic coronary artery dissection Antegrade dissection/re-entry Stingray system ST-segment-elevation myocardial infarction (STEMI) Venoarterial extracorporeal membrane oxygenation (VA-ECMO)

a b s t r a c t Iatrogenic coronary artery dissection is a feared complication of percutaneous coronary intervention as it can potentially lead to severe myocardial ischemia, arrhythmias, shock, and death. Bailout-stenting or less often, emergent coronary artery bypass graft surgery may be needed for restoring antegrade flow. We describe a case of inferior ST-segment elevation acute myocardial infarction with preserved antegrade coronary flow. Percutaneous coronary intervention was complicated by acute right coronary artery closure during guide catheter engagement. Attempts for re-entry into the right coronary artery true lumen failed. Attempts to obtain right femoral arterial access resulted in retroperitoneal hematoma. The patient developed refractory ventricular fibrillation and could not be defibrillated. Veno-arterial extracorporeal membrane oxygenation was started using surgical right femoral cutdown for the venous cannula and the left common femoral artery for the arterial cannula. A dissection strategy with a knuckled guidewire was used around previously placed stents followed by successful re-entry into the distal right coronary artery using the Stingray system. The venous cannula was changed to the internal jugular vein and the right common femoral artery and vein were surgically repaired. The patient was decannulated two days later and was eventually discharged from the hospital neurologically intact. © 2019 Elsevier Inc. All rights reserved.

1. Introduction Iatrogenic coronary artery dissection is an infrequent but potentially life-threatening complication of percutaneous coronary intervention (PCI): its incidence is approximately 0.1% and one-year mortality is 6.1% [1]. Iatrogenic coronary artery dissection can be treated with bailout-stenting or less often emergent coronary artery bypass graft surgery. Occasionally patients with well-developed collateral circulation do not develop chest pain or signs of ischemia, remain hemodynamically stable, and can be treated conservatively [2]. We describe a case of a patient with inferior ST-segment-elevation myocardial infarction (STEMI). Primary PCI attempts via radial access were complicated by right coronary artery (RCA) occlusion. Attempts to obtain femoral access were complicated by formation of a retroperitoneal hematoma. The patient developed ventricular fibrillation requiring initiation of veno-arterial extracorporeal oxygenation (VA-ECMO).

⁎ Corresponding author at: Minneapolis Heart Institute, 920 E 28th Street #300, Minneapolis, MN 55407, USA. E-mail address: [email protected] (E.S. Brilakis).

The occluded RCA was recanalized using dissection/re-entry, leading to recovery. 2. Case report A 70-year-old man presented to the emergency department with acute onset severe retrosternal chest pain and dyspnea. He had type II diabetes mellitus, hypertension, dyslipidemia and had undergone RCA PCI 20 years prior. The electrocardiogram demonstrated inferior STEMI and the patient was referred for primary PCI. Coronary angiography performed via right radial access revealed two consecutive 90% stenoses in the mid and distal RCA due to in-stent restenosis without significant lesions in the left anterior descending and circumflex arteries (Fig. 1, Panel A). The RCA was tortuous and calcified. Engagement of the RCA with a guide catheter was very challenging: We were unable to engage it with an AL1 and an AL 0.75 guide (Medtronic). We finally engaged the RCA using an Ikari Right guide (Terumo) but immediately upon engagement, acute closure occurred leading to STsegment elevation in the inferior leads and worsening chest pain. Multiple attempts were made to wire the true lumen without success, in part due to poor guide catheter support.

https://doi.org/10.1016/j.carrev.2019.03.005 1553-8389/© 2019 Elsevier Inc. All rights reserved.

Please cite this article as: I. Xenogiannis, K. Hryniewicz, M.N. Burke, et al., Salvage of simultaneous acute coronary closure and retroperitoneal bleeding using veno-arterial extr..., Cardiovascular Revascularization Medicine, https://doi.org/10.1016/j.carrev.2019.03.005

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Fig. 1. Panel A: Severe lesions in the distal right coronary artery (RCA, arrows). Panel B: Retrograde crossing of septal collaterals originating from the left anterior descending artery (arrow) failed. Panel C: A knuckled wire was advanced subintimally to the distal RCA. Panel D: A Stingray balloon (Boston Scientific) was delivered distal to the previously placed stents. Panel E: A Gaia 3rd guidewire (Asahi Intecc) was advanced through the Stingray balloon achieving distal true lumen re-entry. Panel F: Deployment of 6 drug eluting stents, crushing the previously implanted stents. Panel G: Intravascular ultrasonography (IVUS) demonstrated good stent expansion and crushing of the previously placed stents (arrow). Panel H: Final result with TIMI 3 flow in the right coronary artery.

We attempted to obtain right femoral access but encountered difficulty in advancing a guidewire through the right external iliac artery because of tortuosity, calcification and the presence of an aneurysm and access was lost. We obtained access through the left femoral artery and continued attempts to re-enter into the RCA true lumen. The patient became severely hypotensive (systolic blood pressure 50–60 mm Hg) and hypoxemic (oxygen saturation 84%). Fluoroscopy demonstrated urinary bladder displacement towards the left side, suggestive of retroperitoneal hematoma (Fig. 2, Panel A). Angiography of the right common femoral artery revealed a perforation with active bleeding. A 8 mm × 20 mm balloon was inflated over the site of the perforation but we were unable to deliver a covered stent (Fig. 2, Panel B). We administered intravenous fluids as well as vasopressin,

norepinephrine and epinephrine. The patient was transfused with 2 units of packed red blood cells. Vascular surgery performed a right groin cut down to repair the perforation. Groin exploration also demonstrated a right iliac vein tear but at the same time the patient developed refractory ventricular fibrillation and could not be defibrillated. Cardiopulmonary resuscitation was initiated with intubation and use of a Lucas device maintaining systolic blood pressure of 60–80 mm Hg. We placed a 17-Fr arterial cannula in the left femoral artery and the vascular surgeon placed a 25-Fr cannula in the right common femoral vein and the patient was started on VA-ECMO. Although the venous cannula partially obliterated the vein, bleeding continued. A venous cannula was inserted via the right jugular vein, followed by surgical repair of the right common femoral artery and vein that achieved hemostasis.

Fig. 2. Panel A: Fluoroscopy demonstrating urinary bladder displacement towards the left side, suggestive of retroperitoneal hematoma. Panel B: A 8 mm × 20 mm balloon was inflated in the right common femoral artery over the site of perforation to stop the bleeding.

Please cite this article as: I. Xenogiannis, K. Hryniewicz, M.N. Burke, et al., Salvage of simultaneous acute coronary closure and retroperitoneal bleeding using veno-arterial extr..., Cardiovascular Revascularization Medicine, https://doi.org/10.1016/j.carrev.2019.03.005

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After the patient stabilized on VA-ECMO, left radial access was obtained using a 7-French slender sheath. Retrograde crossing attempts from the left anterior descending artery to the RCA failed. (Fig. 1, Panel B). The RCA was engaged with a 7-French JR-4 guide catheter (Cordis) and a knuckled Pilot 200 guidewire (Abbott Vascular) was advanced subintimally, distally to the previously implanted mid RCA stent (Fig. 1, Panel C). After predilation with a 1.5 mm balloon, we were able to advance a Stingray balloon (Boston Scientific) subintimally distal to the prior stents (Fig. 1, Panel D). Distal true lumen re-entry was achieved using the Stingray balloon and the double-blind stick and swap technique with a Gaia 3rd guidewire (Asahi Intecc) (Fig. 1, Panel E). The Gaia 3rd was exchanged for a workhorse guidewire, followed by predilation and deployment of 6 drug-eluting stents (Fig. 1, Panel F) with restoration of TIMI 3 antegrade flow. Intravascular ultrasound demonstrated good stent expansion (Fig. 1, Panel G and Panel H). After RCA recanalization patient was successfully defibrillated and was transferred in critical condition to the ICU. At the end of the procedure and while still on VA-ECMO, the patient had a pulmonary capillary wedge pressure of 12 mm Hg. He was decannulated 2 days later. The patient underwent brain magnetic resonance imaging that revealed small recent infarctions within cerebellar and left cerebellar hemispheres. During a prolonged hospital stay, his neurological function improved but he continued to have generalized weakness, dysphagia and cognitive deficits and he was discharged to a rehabilitation center. Before discharge, echocardiography showed normal left ventricular size with an estimated ejection fraction of 50–55%. The right ventricle was moderately enlarged with severely reduced systolic function. One month later, left ventricular ejection fraction was 65% and the right ventricle was mildly enlarged with normal systolic function. Seven months after admission, the patient remained without angina or dyspnea, and was completely functional (able to ride his motorcycle) with his only complaint being fingertip numbness. 3. Discussion Our case illustrates several challenges and potential solutions associated with primary PCI. First, coronary artery engagement can be challenging when using radial access (which is the standard of care for primary PCI), whereas femoral access can lead to severe, lifethreatening bleeding. Second, acute vessel closure can be challenging to treat, but can sometimes be approached using subintimal dissection/ re-entry chronic total occlusion PCI techniques. Third, VA-ECMO can provide cardiopulmonary support in cardiac arrest patients, potentially bridging them to recovery. In addition, in case of femoral vessel injury VA-ECMO drainage can be achieved through cannulation of a jugular vein. Radial access is the standard of care for most PCIs, especially primary PCIs, given multiple studies and meta-analyses demonstrating lower mortality as compared with femoral access [3,4]. The decrease in adverse cardiovascular events is driven by lower bleeding and access site complications. This was illustrated by the retroperitoneal hematoma that complicated attempts for obtaining femoral access in our patient. Differentiating cardiogenic shock from hypovolemic shock can be challenging in the setting of STEMI and acute vessel closure. In our patient pelvic fluoroscopy revealed bladder displacement (Fig. 2, Panel A) suggesting the diagnosis of retroperitoneal hematoma. The “dented bladder” sign is a simple and readily available way to screen for retroperitoneal hematomas [5], provided that several minutes have elapsed from contrast agent administration to allow for bladder opacification. As with all perforations, immediate occlusion with a balloon to stop the bleeding is the first treatment step, followed by implantation of a covered stent. A covered stent could not be delivered in our patient, requiring surgical intervention for controlling the bleeding. Ventricular fibrillation in our patient was likely the combined result of ischemia (due to acute RCA occlusion) and hypovolemia (due to retroperitoneal bleeding) and was refractory to defibrillation. In such cases, extracorporeal cardiopulmonary resuscitation (e-CPR) may

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allow survival by stabilizing the patient [6]. Bleeding is a relative contra-indication to e-CPR, however in our case the source of bleeding (femoral arterial injury) could be surgically repaired. The patient could not be successfully defibrillated until after restoration of RCA antegrade flow, which, however, would not have been possible had the patient not been placed on VA-ECMO. Acute vessel closure can be a life-threating complication and can be caused by engagement of aorto-ostial coronary artery lesions, use of Amplatz catheters, vigorous contrast injection, and deep catheter intubation [2]. In our patient acute RCA closure occurred immediately after engagement with a guide catheter and led to chest pain and worsening ST-segment elevation. Re-entering into the true lumen, followed by stent implantation can restore antegrade flow and relieve the ischemia, but this can be challenging in the presence of extensive dissections. Reentry into the distal true lumen, using CTO PCI techniques has been used to treat acute vessel closure [7,8]. Retrograde crossing is another CTO PCI technique that has been successful in this setting [9,10], but collateral circulation is usually poorly developed given lack of a longstanding lesion and may be impossible to cross. The subintimal tracking and re-entry (STAR) technique can be used by advancing a knuckled guidewire until it re-enters into several distal small branches restoring antegrade flow without stent implantation [11]. The STAR technique is, however, associated with high restenosis and reocclusion rates and should only be used as last resort [12–14]. Similar to prior reports, antegrade dissection and re-entry was successfully utilized in our patient [7,8]. The presence of a previously implanted stent created additional challenges that were overcome by sub-stent guidewire crossing, reentry using the Stingray system, and crushing of the prior stents. Such strategy has been associated with favorable subsequent clinical outcomes in a recent 32 patient study [15]. However, using advanced CTO PCI techniques to treat complications should be done by operators and centers with extensive experience in the field. 4. Conclusion Preventing complications is preferable to treatment, but should complications occur, having additional treatment options is invaluable. Acute vessel closure occurred during attempts to engage the RCA through radial access. Retroperitoneal hematoma developed, even though radial access was used first and despite obtaining femoral access using ultrasound guidance and a micropuncture needle. Use of VAECMO and CTO PCI techniques allowed patient salvage.

Disclosures Dr. Xenogiannis: nothing to disclose. Dr. Hryniewicz: nothing to disclose. Dr. Burke: consulting and speaker honoraria from Abbott Vascular and Boston Scientific. Dr. Brilakis: consulting/speaker honoraria from Abbott Vascular, American Heart Association (associate editor Circulation), Amgen, Boston Scientific, Cardiovascular Innovations Foundation (Board of Directors), CSI, Elsevier, GE Healthcare, InfraRedx, and Medtronic; research support from Siemens, and Regeneron. Shareholder: MHI Ventures. Board of Trustees: Society of Cardiovascular Angiography and Interventions.

References [1] Ramasamy AJD, Wragg A, Smith EJ, Knight CJ, Mathur A, O'Mahony C. 16 Iatrogenic catheter induced coronary artery dissection: incidence, management and outcomes. Heart 2017;103:A7–A8 2017. [2] Boyle AJ, Chan M, Dib J, Resar J. Catheter-induced coronary artery dissection: risk factors, prevention and management. J Invasive Cardiol 2006;18:500–3. [3] Valgimigli M, Gagnor A, Calabro P, et al. Radial versus femoral access in patients with acute coronary syndromes undergoing invasive management: a randomised multicentre trial. Lancet 2015;385:2465–76.

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[4] Ando G, Capodanno D. Radial access reduces mortality in patients with acute coronary syndromes: results from an updated trial sequential analysis of randomized trials. JACC Cardiovasc Interv 2016;9:660–70. [5] Cilingiroglu M, Hakeem A. Revisiting the “dented bladder”—a bona fide sign of retroperitoneal bleed. Catheter Cardiovasc Interv 2012;79:166. [6] Ouweneel DM, Schotborgh JV, Limpens J, et al. Extracorporeal life support during cardiac arrest and cardiogenic shock: a systematic review and meta-analysis. Intensive Care Med 2016;42:1922–34. [7] Shaukat A, Mooney M, Burke MN, Brilakis ES. Use of chronic total occlusion percutaneous coronary intervention techniques for treating acute vessel closure. Catheter Cardiovasc Interv 2018;92(7):1297–300. [8] Martinez-Rumayor AA, Banerjee S, Brilakis ES. Knuckle wire and stingray balloon for recrossing a coronary dissection after loss of guidewire position. JACC Cardiovasc Interv 2012;5:e31–2. [9] Costello-Boerrigter LC, Salomon C, Bufe A, Lapp H. The novel use of retrograde CTO PCI techniques as a rescue strategy for an acute right coronary artery occlusion due to iatrogenic dissection. J Cardiol Cases 2018;17:89–91.

[10] Kotsia ABS, Brilakis E. Acute vessel closure salvaged by use of the retrograde approach. Interv Cardiol 2014;6(2):145–7. https://doi.org/10.2217/ica.14.3 (Apr 2014). London. [11] Carlino M, Al-Lamee R, Ielasi A, et al. Treatment of iatrogenic occlusive coronary dissections: a novel approach. EuroIntervention 2011;7:106–11. [12] Godino C, Latib A, Economou FI, et al. Coronary chronic total occlusions: midterm comparison of clinical outcome following the use of the guided-STAR technique and conventional anterograde approaches. Catheter Cardiovasc Interv 2012;79:20–7. [13] Karatasakis A, Danek BA, Karacsonyi J, et al. Mid-term outcomes of chronic total occlusion percutaneous coronary intervention with subadventitial vs. intraplaque crossing: a systematic review and meta-analysis. Int J Cardiol 2018;253:29–34. [14] Valenti R, Vergara R, Migliorini A, et al. Predictors of reocclusion after successful drug-eluting stent-supported percutaneous coronary intervention of chronic total occlusion. J Am Coll Cardiol 2013;61:545–50. [15] Azzalini L, Karatasakis A, Spratt JC, et al. Subadventitial stenting around occluded stents: a bailout technique to recanalize in-stent chronic total occlusions. Catheter Cardiovasc Interv 2018;92(3):466–76.

Please cite this article as: I. Xenogiannis, K. Hryniewicz, M.N. Burke, et al., Salvage of simultaneous acute coronary closure and retroperitoneal bleeding using veno-arterial extr..., Cardiovascular Revascularization Medicine, https://doi.org/10.1016/j.carrev.2019.03.005