Case Report

Successful Management of Saphenous Vein Graft Perforation: A Disaster Avoided

Abha Kulkarni, MS2a; Mihika Shah, MS2a; Joseph Ibrahim, MDb,c; Shray Awasti, RAa

Riya-Aisha Patel, RAc; Ashish Awasti, MD FACCa; Pratik B. Patel, MD, FACCa,c

Abha Kulkarni, MS2a; Mihika Shah, MS2a; Joseph Ibrahim, MDb,c; Shray Awasti, RAa

Riya-Aisha Patel, RAc; Ashish Awasti, MD FACCa; Pratik B. Patel, MD, FACCa,c

Coronary artery perforation (CAP) is a rare but serious, and potentially fatal, complication of percutaneous coronary intervention (PCI). CAP occurs when an intimal tear or dissection penetrates the arterial wall. Previous studies estimate the incidence of CAP during PCI is between 0.2 and 0.6%.1-4 While this is a rare event, it can lead to life-threatening complications, including cardiac tamponade. 

CAPs are typically classified according to the Ellis Classification System:

Type I: Extraluminal crater without extravasation

Type II: Pericardial or myocardial blush without contrast jet extravasation 

Type III: Extravasation through frank (≥1mm) perforation

Cavity spilling: Perforation into an anatomic cavity chamber, coronary sinus, etc.

There are many clinical and technique-associated risk factors associated with CAP. These include advanced age, female sex, and the use of atherectomy devices. 

CAP can occur in native coronary arteries or in bypass grafts. PCI in bypass grafts tends to be associated with worse clinical outcomes, including higher rates of in-hospital mortality, no reflow, and periprocedural myocardial infarction,5 which could be explained in part by the higher risk profile and complex lesion morphology of patients with bypass grafts. 

We report the unique case of a patient who underwent PCI and experienced saphenous vein graft (SVG) perforation, leading to severe hypotension. The case was successfully managed through the use of balloon occlusion and covered coronary stents. 

Case Report

A 76-year-old female presented with unstable angina. She had a past medical history significant for coronary artery disease (CAD), status post coronary artery bypass graft (CABG) surgery, PCI of the native coronaries, and PCI of the SVG to the RCA, peripheral artery disease (PAD), hypertension, hyperlipidemia, chronic kidney disease stage III, and diabetes mellitus type 2. A previous cardiac catheterization had been done at a community hospital and she was transferred to a tertiary hospital for PCI to repair the SVG. Regarding her PAD, she had a history of several peripheral stents in her lower extremities, including bilateral aorto-iliac arteries. Her CABG was performed 22 years prior, in 1997, with proximal and distal stents placed in the SVG to the RCA 13 years prior, in 2006. In recent months, the patient had been experiencing angina and chronic heart failure-like symptoms, including shortness of breath on exertion, prompting her most recent evaluation and treatment. Two months prior to admission, the patient underwent an echocardiogram revealing decreased ejection fraction with moderate inferior wall hypokinesis. A few weeks prior to admission, the patient underwent a cardiac catheterization showing that 2 of the 3 bypass grafts were functioning. On the day of admission, she came in for an elective PCI to the SVG with multiple stenotic lesions. 

A 21-gauge Angiocath needle (BD) was used to access the radial artery. However, due to extensive plaque in the subclavian and aortic area, the access point was switched to the right femoral artery. A 6 French multi-purpose (MP) catheter was advanced to engage SVG to the RCA. Coronary angiography of the SVG to RCA revealed several severe, sequential stenoses. The distal stenosis appeared severely diseased and calcified, and was resistant to balloon passage. Laser atherectomy was performed, followed by balloon angioplasty and stenting. 

During the procedure, the patient became hypotensive. Coronary artery injections revealed perforation at the level of the distal lesion that was not caused by the insertion of the catheter. The perforation was initially treated by balloon occlusion and the patient was given protamine to reverse the effects of heparin (anticoagulation). Because of the perforation, the angioplasty balloon was left inflated via the right radial access to temporarily occlude the SVG to the RCA. In the meantime, right femoral artery access was obtained and a 7 French Judkins Right (JR) 4 guide catheter was placed at the ostium of the SVG to the RCA to allow for the preparation and delivery of Graftmaster stents (Abbott Vascular). Two Graftmaster covered stents were deployed in an attempt to the seal the graft perforation. However, persistent dye extravasation was noted, filling up the mediastinum. The patient required urgent intubation due to respiratory distress, intravenous pressor support, and transient cardiopulmonary resuscitation before a return of spontaneous circulation (ROSC) was obtained. An echocardiogram revealed no pericardial effusion and slightly depressed left ventricular function. 

To seal the persistently perforated SVG, another covered stent was needed, which required a larger guide catheter. To avoid deflating the balloon, which was effectively occluding the SVG, an Amplatz left (AL) 1 guide was inserted into the right radial artery, and a wire and balloon advanced. The original balloon was deflated and the new balloon was inflated, effectively maintaining blood pressure. The original guide was exchanged in favor of a new 8 French guide and a final Graftmaster covered stent was deployed. 

At the conclusion of the case, there was no longer any evidence of perforation. The patient was normotensive on small dose of Levophed (norepinephrine bitartrate) and oxygenating well on the ventilator. Cardiothoracic surgery was consulted and the patient was admitted to the cardiac care unit for further treatment. She was extubated the following day. Repeat echo showed no pericardial effusion and improved left ventricular systolic function, with no regional wall motion abnormality.  

Discussion 

Coronary artery perforation (CAP) is a rare complication of PCI, occurring in 0.2-0.6% of procedures. Although uncommon, it is a serious event that can lead to potentially fatal complications such as cardiac tamponade, arrhythmias, respiratory compromise, and death. During PCI, CAP can occur in native coronary arteries or, rarely, in saphenous vein bypass grafts (SVG). Although the exact incidence of vessel perforation in bypass grafts as compared to native coronary arteries remains unknown, PCI in an SVG is associated with worse clinical outcomes than PCI in native coronary arteries, including higher rates of in-hospital mortality, no reflow, and periprocedural myocardial infarction.5 These worse outcomes could be explained in part by the higher risk profile and more complex lesion morphology of patients undergoing SVG PCI.5 Additionally, bypass grafts are prone to accelerated atherosclerosis and degeneration as compared to native coronary arteries, which could contribute to higher rates of complications during, and worse outcomes following, PCI.6 Complications of a perforation of the SVG also include potential hemorrhage in mediastinum and collapse of the lungs. 

There are many clinical and technique-associated risk factors associated with CAP. Clinical factors predictive of CAP include advanced age, female sex, renal impairment, and non-ST-elevation myocardial infection patients. Technique-associated factors include the use of atherectomy devices, increased balloon-to-artery ratio, use of hydrophilic or extra-stiff wires, and cutting balloons.7 In this case, the patient had a number of risk factors for vessel perforation, including advanced age, female sex, and the use of an atherectomy device. 

Iatrogenic CAP requires urgent treatment and management, and can involve the use of a number of techniques.8 

1. Covered stents are used to seal perforations with a layer impermeable to blood. Covered stents are used more commonly in proximal vessel segments, where perforation is typically caused by use of balloons or other devices. The use of covered stents has improved survival following CAP and reduced the need for emergent cardiac surgery. However, covered stents have a number of disadvantages: they increase the risk of side branch occlusion, are inflexible, and may increase thrombogenicity. However, newer versions have improved flexibility and decrease thrombogenicity. 

2. Coils are metallic devices with wired structures made of synthetic wool or Dacron fibers. They have thrombogenic properties and are implanted permanently. The size of the catheter used to deploy the coil depends on how distal the desired placement, with microcatheters used for more distal delivery. Coil size must be chosen carefully to ensure vessel adherence and embolization, while avoiding early deployment or distal migration.  

Previous studies have shown that covered stents are used more frequently than coils during CAP. In this case, Graftmaster stents were deployed to seal the perforation: two were deployed after the perforation was discovered and a third was deployed when the perforation persisted. 

Conclusion

This article describes the successful management of SVG perforation during PCI using balloon occlusion, covered stents, and medical management. Through prompt decision-making and ingenuity, the potentially life-threatening complications of this serious event were avoided. 

aRobert Wood Johnson University Hospital, New Brunswick, New Jersey; bUniversity of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; cCardio Metabolic Institute, Somerset, New Jersey

Disclosures: The authors report no conflicts of interest regarding the content herein.

The authors can be contacted via Joseph Ibrahim, MD, at ibrahimj3@upmc.edu. 

References
  1. Fasseas P, Orford JL, Panetta CJ, et al. Incidence, correlates, management, and clinical outcome of coronary perforation: analysis of 16,298 procedures. Am Heart J. 2004; 147(1): 140-145. doi:10.1016/s0002-8703(03)00505-2
  2. Witzke CF, Martin-Herrero F, Clarke SC, et al. The changing pattern of coronary perforation during percutaneous coronary intervention in the new device era. J Invasive Cardiol. 2004; 16(6): 257-301.
  3. Ramana RK, Arab D, Joyal D, et al. Coronary artery perforation during percutaneous coronary intervention: incidence and outcomes in the new interventional era. J Invasive Cardiol. 2005; 17(11): 603-605.
  4. Ekici B, Erkan AF, Kütük U, Töre HF. Successful management of coronary artery rupture with stent-graft: a case report. Case Rep Med. 2014; 2014: 391843. doi:10.1155/2014/391843
  5. Brilakis ES, Rao SV, Banerjee S, et al. Percutaneous coronary intervention in native arteries versus bypass grafts in prior coronary artery bypass grafting patients: a report from the National Cardiovascular Data Registry. JACC Cardiovasc Interv. 2011; 4(8): 844-850. doi:10.1016/j.jcin.2011.03.018
  6. Safian RD. Accelerated atherosclerosis in saphenous vein bypass grafts: a spectrum of diffuse plaque instability. Prog Cardiovasc Dis. 2002; 44(6): 437-448. doi:10.1053/pcad.2002.123471
  7. Al-Mukhaini M, Panduranga P, Sulaiman K, et al. Coronary perforation and covered stents: an update and review. Heart Views. 2011; 12(2): 63-70. doi:10.4103/1995-705X.86017
  8. Lemmert ME, van Bommel RJ, Diletti R, et al. Clinical characteristics and management of coronary artery perforations: a single-center 11-year experience and practical overview. J Am Heart Assoc. 2017; 6(9): e007049. doi:10.1161/JAHA.117.007049