Successful treatment of distal coronary guidewire‐induced perforation with balloon catheter delivery of intracoronary thrombin

Abstract

Distal coronary artery perforation with a coronary guidewire is a relatively rare but potentially fatal complication during PTCA. Historically, these types of perforations have been easy to control with reversal of heparin anticoagulation combined with prolonged distal balloon inflation. In the modern era, with widespread use of potent glycoprotein IIb/IIIa inhibitors, this type of distal wire perforation has become more difficult to manage and potentially lethal. In this article, we report two cases of guidewire-related distal coronary artery perforation, successfully treated using a new technique using localized, distal intracoronary thrombin injection. During prolonged low-pressure balloon inflation, a small dose of thrombin was injected just proximal to the wire perforation site via the lumen of a coronary balloon catheter. This approach appears to be a relatively rapid and effective way to control this troublesome complication.

Endovascular treatment of a massive retroperitoneal bleeding: Successful balloon-catheter delivery of intra-arterial thrombin

“…In contrast to the use of microcoils, polyvinyl alcohol, and gelfoam, thrombin is readily available in most catheterization laboratories and perhaps less technically demanding. On the other hand, it can potentially lead to thrombotic embolization if the interventionist is not meticulous with the technique, or when adequate selectivity and isolation of the target vessel is not accomplished with balloon occlusion [17]. Thrombin induces platelet aggregation and fibrin production leading to vessel thrombosis, even when strong antiplatelets such as the GP IIb/IIIa inhibitors and/or thienopyridines have been administered, as shown in the present and a previous coronary report [17].…”

“…Only two case reports have been published in the literature, of which one was performed intraoperatively [13,14] and the other percutaneously [5]. Previous reports have also described the use of microcoils [14], or chemical procoagulant substances such as polyvinyl alcohol, gelfoam, [15,16], and, more recently, natural procoagulants such as thrombin [17], to induce arterial thrombosis after coronary guidewire perforation unsuccessfully sealed with prolonged balloon inflation. The present case report describes a combination of balloon occlusion and the successful use of catheter-directed intra-arterial thrombin to induce thrombosis of a lacerated inferior epigastric artery and hemostasis of a massive retroperitoneal bleeding.…”

Wire Induced Coronary Perforation Finally Terminating into Contained Myocardial Rupture – A Case Report

“…Attempts to closure of the bleeding vessel can be made using prolonged balloon inflation alone or embolization of microcoils, thrombus, fat particles, or intra arterial glue as described by earlier [1][2][3][4][5][6][7][8][9].…”

“…These are also the commonest cause for an overlooked perforation during the procedure, the leak being slow, and patient presenting with pericardial effusion and tamponade only in the post procedure period once he/she is shifted to the ward. Nearly half of these are self terminating with medical management and the other half require a closure of the leaking twig using micro coils, thrombus, fat particles, glue or otherwise [1][2][3][4][5][6][7][8][9]. Interventional management is usually successful except in rare cases.…”

Surgical removal of a fractured guidewire entrapped in the coronary artery

“…Similarly, Fischell et al reported two patients with guidewirerelated distal coronary artery perforation who were successfully treated by localized distal intracoronary thrombin injection. 2 Dixon et al described a case that was occluded by distal Gelfoam embolization via an infusion catheter for a distal coronary artery guidewire perforation. 3 Darwazah et al reported two patients in whom a fractured guidewire became entrapped during angioplasty.…”