V stenting technique with covered stents for the management of ostial circumflex perforation: Good or bad idea?

Abstract

We report the case of a redo Ross surgery complicated by an ostial left circumflex occlusion requiring emergent percutaneous coronary intervention. The latter was complicated by coronary perforation treated by two covered stents with V-stenting technique. After immediate success, the clinical course was marked by acute stent thrombosis requiring emergent coronary bypass.

Learning objectives

Ostial left circumflex perforation is a rare and potentially fatal complication that is challenging to manage. V stenting technique with two covered stents could be used as a life-saving procedure, but is associated with a high thrombotic risk.

Introduction

Coronary perforation is a serious complication of percutaneous coronary intervention (PCI). A covered stent is often necessary when dealing with a large epicardial artery. Perforations that occur at the site of a bifurcation are an even more challenging situation. Here, we report the case of a redo Ross surgery complicated by an ostial left circumflex (LCX) occlusion requiring emergent PCI. The re-opening was complicated by an ostial LCX perforation.

Case report

Past medical history and presentation

We present the case of a 35-year-old male who underwent Ross surgery 15 years previously for severe bicuspid aortic valve stenosis, without aortic root enlargement. He now presented with New York Heart Association class 2 dyspnea due to severe aortic regurgitation with autograft dilatation and pulmonary valve degeneration. Redo surgery was decided and a mechanical Bentall intervention was performed (conservative surgery was considered but finally not possible) combined with pulmonary valve replacement and tricuspid annuloplasty.

The surgery was technically challenging and required a long operative time. The cardiopulmonary bypass was weaned with minimal vasoactive drugs. A Few minutes following admission in the critical care unit, heart monitor and electrocardiography (ECG) revealed an inferior ST-elevation myocardial infarction. Transesophageal echocardiography showed a left ventricular ejection fraction (LVEF) of 40 % with inferior hypokinesia, no pericardial effusion, and valves functioning normally. An emergency coronary angiogram demonstrated a new total occlusion of the ostium of the LCX (Video 1).

We suspected mechanical obstruction from a suture stitch used to control bleeding in the left main (LM) area. Atherosclerosis-related coronary occlusion was unlikely given the normal preoperative computed tomography angiography (CTA).

Management

After discussion with the heart team, the patient was deemed at prohibitive risk for emergent coronary bypass grafting (CBG) so a PCI was performed to revascularize the LCX artery. Via 6Fr radial access, LM was engaged with an XB 3.5 guiding catheter (GC) (Cordis, US), LCX was wired with a Sion blue (Asahi, Japan) over a 90° angulated microcatheter Supercross (Teleflex, US). A safety wire was also inserted in the left anterior descending artery (LAD). Balloon predilation of the ostial LCX was carefully performed to avoid a rupture with gradual upsizing of the balloon from 1.5 mm to achieve a thrombolysis in myocardial infarction (TIMI) III flow (Fig. 1, Video 2). Immediately after the 2.75 mm balloon inflation, aortic blood pressure dropped and blood was collected through the pericardial drain. Perforation of the ostial of the LCX was demonstrated. A non-compliant 2.75 mm balloon was quickly inflated from the LM to the proximal LCX to seal the perforation. Small contrast injection confirmed the patency of the LM/LAD (Video 3).

Fig. 1.

Management of left circumflex artery (LCX) occlusion. Wiring of both left anterior descending artery and LCX (A); Predilation with increasing size non-compliant balloon (herein 2.75 mm balloon) (B); Angiogram showing LCX thrombolysis in myocardial infarction III flow restoration associated with contrast extravasation suggesting an ostial LCX perforation (see arrow) (C).

Fifteen minutes of balloon tamponade did not achieve hemostasis.

Several options were discussed to manage this complication. Emergent LM repair surgery seemed hazardous given the hemodynamic instability and the complexity of the procedure, which would have required the removal of both the pulmonary prosthesis and the Bentall distal anastomosis in order to patch the LM-LCX bifurcation. It was also unlikely that topical hemostatic agents could achieve durable hemostasis.

Regarding the percutaneous management strategy, nailing the LCX ostium with a single covered stent would have exposed us to the risks of hemostasis failure and LAD occlusion. “V” stenting with two covered stents from LM to LAD and LM to LCX was considered the best option to quickly seal the perforation while ensuring the patency of LAD.

Ping Pong technique was performed: 8 Fr femoral sheath was inserted to engage the LM with an 8F XB 3.5 GC (Cordis) and wire LAD then LCX after a transient deflation of the hemostatic balloon (Video 3). Two covered PAPYRUS stents (Biotronik, Germany), (3.5 × 20 mm for LAD and 3 × 15 mm for LCX) were advanced to the tip of the 8F GC. The hemostatic balloon and its wire were then removed from the radial GC and the two covered stents were advanced and inflated from the ostium of the LM to both the LAD and the LCX. The final coronary angiogram showed no residual contrast extravasation and both LAD and LCX patency (Fig. 2, Video 4).

Fig. 2.

V stenting with two covered stents. Two covered PAPYRUS stents (Biotronik, Germany) (3.5 × 20 mm for LAD and 3 × 15 mm for LCX) were advanced and inflated (A, B); Final coronary angiogram showing both LAD and LCX patent and no longer any contrast extravasation (C)

LAD, left anterior descending artery; LCX, left circumflex artery.

The patient remained stable in the intensive care unit under triple antithrombotic therapy (unfractionated heparin, aspirin, and clopidogrel). On day 7, the patient presented acute hemodynamic instability and ECG modifications. A coronary angiogram showed LCX acute stent thrombosis. Thromboaspiration and balloon angioplasty were performed to restore a TIMI III flow (Video 5). A glycoprotein IIb/IIIa inhibitor was administered on top of the triple antithrombotic therapy for 24 h. The clinical status of the patient improved. Three days later, a coronary angiogram showed both LAD and LCX patency with some residual in-stent thrombotic material. Endocoronary imaging with optimal coherence tomography (OCT) was attempted to evaluate the expansion of the covered stents. Unfortunately, the insertion of the OCT catheter was complicated by an acute LAD occlusion caused by thrombotic migration, leading to a refractory cardiac arrest and extracorporeal membrane oxygenation (ECMO) implantation. LAD occlusion was successfully treated by thromboaspiration and balloon angioplasty to achieve a TIMI III flow with some residual thrombotic material (Video 6).

As the patient remained in critical condition, a heart transplant was considered but the patient was not eligible because of a high degree of allo-immunization. Given the very high risk of repeated stent thrombosis, CBG was performed on day 14 using a venous graft on the LAD. LCX was not grafted to decrease the time of the procedure and because this myocardial territory was considered necrotic. Evolution was then slowly favorable with ECMO removal on day 20 and discharge to the cardiology ward on day 23.

Follow up

The patient was finally discharged on day 52 with a LVEF of 25 % and a 1-year-long triple antithrombotic therapy combining aspirin, clopidogrel, and vitamin K antagonist (VKA) before de-escalation to a single antiplatelet therapy plus VKA. A coronary CTA performed before discharge (on day 47) showed the patency of both the covered stents and the venous graft to LAD (Fig. 3A). At 6 months, a coronary CTA showed a complete thrombosis of the venous graft with a patency of the covered stents (Fig. 3B).

Fig. 3.

Post-operative coronary computed tomography angiography. Covered stents and venous graft to left anterior descending artery patent at day 47 (A); 2 covered stents patent and venous graft occluded (red circle) at 6 months (B).

Discussion

To the best of our knowledge, V stenting using two covered stents to manage an LCX ostium perforation had never been described. Moriyama et al. reported the case of a distal LM perforation after atherectomy managed successfully with a V stenting technique with a PTFE-covered stent in the LM-LAD and a drug-eluting stent in LM-LCX [1]. Others have described LM perforation during chronic total occlusion procedure managed with a covered stent implanted from the LM to LCX followed by fenestration of the covered stent by a stiff wire toward the LAD [2]. These two last options were not chosen because we were not confident to seal the perforation with the first one, and we would have threatened the LAD patency with the second one while the patient was already unstable hemodynamically. V stenting with two covered stents was assumed to provide the best compromise between bleeding control and preserved vessel patency. The immediate result was satisfying and support that this strategy should be considered. However, as illustrated by the present case report, the thrombotic risk could be very high. In a recent registry, the use of covered stent (Papyrus) has been associated with a target lesion revascularization of 17 % after one year including 8 % of stent thrombosis [3]. To the best of our knowledge, there is no consensus on the optimal duration of antithrombotic therapy after covered stent implantation nor after covered stent thrombosis.

Other factors may have also played a role in stent thrombosis, such as the enhanced inflammatory response associated with cardiogenic shock and the reduced bioavailability of clopidogrel. Overall, the optimal strategy to manage an ostial LCX perforation remains to be defined.

Conclusion

The Ross redux surgery remains a complex intervention associated with a substantial risk of coronary complications. An ostial LCX coronary perforation per PCI is a challenging and life-threatening complication that can be managed by the V-stenting technique with two covered stents protruding in the LM but exposed to a very high thrombotic risk.

The following are the supplementary data related to this article.

Video 1

Emergent coronary angiogram. Acute thrombolysis in myocardial infarction grade 0 occlusion of the left circumflex artery ostium while right coronary artery, left main, and left anterior descending artery were patent.

Video 2

Management of left circumflex artery (LCX) occlusion. Both left anterior descending artery (LAD) and LCX were wired (A); Predilation with increasing size non-compliant balloons were performed (herein 2.75 mm balloon) was performed (B); Angiogram results showing restored thrombolysis in myocardial infarction grade 3 flow in the LCX associated with contrast extravasation suggesting an ostial LCX perforation (C).

Video 3

Management of ostial left circumflex artery (LCX) perforation. Inflation of a 2.75 non-compliant balloon to get hemostasis on the LCX ostium; left main and left anterior descending artery (LAD) were confirmed to be patent (A). 6F radial guiding catheter with both wires one in the LAD and the other in the LCX with the hemostatic balloon; 8F femoral guiding catheter with both wires one in the LAD and the other going through the ostium of the LCX during a transient hemostatic balloon deflation (B).

Video 4

V stenting with two covered stents. Two covered PAPYRUS stents (Biotronik) [(3.5 × 20 mm for left anterior descending artery (LAD) and 3 × 15 mm for left circumflex artery (LCX)] were advanced and inflated (A, B); the Final coronary angiogram showed patent both LAD and LCX and no longer any contrast extravasation from the LCX (C).

Video 5

Acute stent thrombosis on left circumflex artery (LCX). LCX covered stent thrombosis (A) and result after thromboaspiration and balloon angioplasty (B).

Video 6

Systematic control angiogram. Left anterior descending artery (LAD) and left circumflex artery (LCX) both thrombolysis in myocardial infarction grade (TIMI) III (A); Optical coherence tomography (OCT) run in the LCX (B); OCT run in the LAD covered stent (C); LAD occlusion after OCT run (D); restoration of TIMI III flow on LAD and LCX after thromboaspiration and balloon angioplasty (E).

Consent statement

Written informed consent was obtained from the patient for publication of this case report.

Declaration of competing interest

The authors have reported that they have no relationships relevant to the contents of this paper to disclose.