Bifurkasyon Lezyonlarında Komplikasyon Yönetimi
Özet
Perkütan koroner girişimler sırasında bifurkasyon lezyonlarında gelişebilen komplikasyonlar ve bunların yönetim stratejileri, klinik başarının sürdürülmesinde kritik öneme sahiptir. İşlem sonrası akım kaybına neden olan koroner no-reflow fenomeni ve ani damar tıkanmaları; kılavuz tel pozisyonunun korunması, IVUS kullanımı, uygun farmakoterapi ve provizyonel stent stratejileriyle yönetilir. Ellis sınıflamasına göre üç tipe ayrılan koroner perforasyonlar ve intramural hematomlar; perfore alanda uzun süreli düşük basınçlı balon şişirilmesi, greft kaplı stentler, koil embolizasyonu veya acil cerrahiyle tedavi edilir. Bifurkasyon bölgelerindeki metal yükü ve malapozisyonla ilişkili hiperakut stent trombozu riskine karşı ikili antiplatelet tedavi, POT ve double kissing balon dilatasyonu koruyucu role sahiptir. Kılavuz kateterlerin yol açtığı iatrojenik aort diseksiyonu, ostial lezyonlarda tam stent kaplaması gerektirir. Yan dal oklüzyon riskini öngörmede RESOLVE skorlaması kullanılırken; hapsolan tellerin kopması loop-snare veya balon tuzak yöntemleriyle, başarısız tekrar telleme ise balon backstop veya dual lümen mikrokateter teknikleriyle çözülür. Son olarak, hava embolisi %100 oksijen ve aspirasyonla; kontrast alerjileri ise uygun premedikasyon ve antihistaminiklerle yönetilmektedir.
Complications developing in bifurcation lesions during percutaneous coronary interventions and their management strategies are critical for maintaining clinical success. Post-procedural flow loss caused by the coronary no-reflow phenomenon and abrupt vessel closure is managed by maintaining the guidewire position, using IVUS, appropriate pharmacotherapy, and provisional stent strategies. Coronary perforations, categorized into three types based on the Ellis classification, and intramural hematomas are treated with prolonged low-pressure balloon inflation at the perforated site, covered stents, coil embolization, or emergency surgery. To mitigate hyperacute stent thrombosis risks associated with metal load and malapposition at bifurcation sites, dual antiplatelet therapy, POT, and double kissing balloon dilatation play a protective role. Catheter-induced iatrogenic aortic dissection necessitates complete stent coverage in ostial lesions. The RESOLVE scoring system predicts side branch occlusion risks, while jailed wire fractures are addressed using loop-snare or balloon trap techniques, and failed rewiring is resolved with techniques like balloon backstop or dual lumen microcatheters. Finally, air embolisms are treated with 100% oxygen and aspiration, whereas contrast allergies are managed via proper premedication and antihistamines.
Referanslar
Rezkalla SH, Kloner RA.Coronary no-reflow phenomenon: from the experimental laboratory to the cardiac catheterization laboratory. Catheter Cardiovasc Interv. 2008; 72:950-7.
Kaur G, Baghdasaryan P, Natarajan B, et al.Pathophysiology, Diagnosis, and Management of Coronary No-Reflow Phenomenon. Int J Angiol. 2021; 30:15-21.
Gupta S, Gupta MM.No reflow phenomenon in percutaneous coronary interventions in ST-segment elevation myocardial infarction.Indian Heart J. 2016; 68:539-51.
Caiazzo G, Musci RL, Frediani L, et al.State of the Art: No-Reflow Phenomenon.Cardiol Clin. 2020; 38:563-573.
Kelly RV, Cohen MG, Stouffer GA. Incidence and management of no-reflow following percutaneous coronary interventions. Am J Med Sci. 2005; 329:78-85
Giannini F, Candilio L, Mitomo S, et al.A Practical Approach to the Management of Complications During Percutaneous Coronary Intervention.JACC Cardiovasc Interv. 2018; 11:1797-1810.
Huber MS, Mooney JF, Madison J, Mooney MR.Use of a morphologic classification to predict clinical outcome after dissection from coronary angioplasty. Am J Cardiol 1991; 68:467–71.
Klein L. Coronary complications of percutaneous coronary interventions: a practical approach to the management of abrupt closure. Catheter Cardiovasc Interv 2005;64:395–401.
de Feyter PJ, de Jaegere PPT, Murphy ES,Serruys PW. Abrupt coronary artery occlusion during percutaneous transluminal coronary angioplasty.Am Heart J 1992;123:1633–42.
Al-Mukhaini M, Panduranga P, Sulaiman K, et al. Coronary perforationand covered stents: an update and review.Heart Views 2011;12:63–70.
Kinnaird T, Kwok CS, Kontopantelis E, et al.Incidence, determinants and outcomes of coronary perforation during percutaneous coronary intervention in the United Kingdom between 2006 and 2013. An analysis of 527121 cases from the British Cardiovascular Intervention Society Database. Circ Cardiovasc Interv 2016; 9:e003449.
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 ,journal of the American Heart Association. 2017;6:e007049
Shimony A, Joseph L, Mottillo S, Eisenberg MJ.Coronary artery perforation during percutaneous coronary intervention: a systematic review and meta-analysis. Can J Cardiol 2011;27:843–50.
Shirakabe A, Takano H, Nakamura S, et al.Coronary perforation during percutaneous coronary intervention. Int Heart J 2007;48:1–9.
Gunning MG, Williams IL, Jewitt DE, et al.Coronary artery perforation during percutaneous intervention: incidence and outcome. Heart 2002; 88:495–8.
Maehara A, Mintz GS, Bui AB, et al. Incidence, morphology, angiographic findings, and outcomes of intramural hematomas after percutaneous coronary interventions: an intravascular ultrasound study.Circulation. 2002; 105:2037-42.
Antonsen L, Thayssen P, Jensen LO.Large coronary intramural hematomas: a case series and focused literature review.Cardiovasc Revasc Med. 2015; 16:116-23.
Moses JW, Leon MB, Popma JJ, et al. Sirolimus-eluting stents versus standard stents in patients with stenosis in a native coronary artery. N Engl J Med 2003; 349:1315-1323.
Lemesle G, Delhaye C, Bonello L, et al.Stent thrombosis in 2008: definition, predictors, prognosis and treatment. Arch Cardiovasc Dis. 2008; 101:769-77.
Eisenstein EL, Anstrom KJ, Kong DF, et al. Clopidogrel use and long-term clinical outcomes after drug-eluting stent implantation. JAMA 2007; 297:159-168.
Iván J. Núñez-Gil, Daniel Bautista, Enrico Cerrato, et al. Incidence, Management, and Immediate- and Long-Term Outcomes After Iatrogenic Aortic Dissection During Diagnostic or Interventional Coronary Procedures Circulation. 2015;131:2114–2119.
Boukhris M, Tomasello SD, Marzà F, Azzarelli S, Galassi AR. Iatrogenic aortic dissection complicating percutaneous coronary intervention for chronic total occlusion. Can J Cardiol. 2015; 31:320-7.
Jia-Chen Li , Xin-Liang Guan , Ming Gong , Hong-Jia Zhang. Iatrogenic aortic dissection during percutaneous coronary intervention: A case report and review of the literature. J Int Med Res. 2018; 46:526-532.
Lunardi M, Louvard Y, Lefèvre T, et al. Definitions and Standardized Endpoints for Treatment of Coronary Bifurcations. EuroIntervention. 2022 May 18:EIJ-E-22-00018. doi: 10.4244/EIJ-E-22-00018. Epub ahead of print. PMID: 35583108
Dou K, Zhang D, Xu B, et al.An angiographic tool for risk prediction of side branch occlusion in coronary bifurcation intervention: the RESOLVE score system (Risk prEdiction of Side branch OccLusion in coronary bifurcation interVEntion). JACC Cardiovasc Interv. 2015; 8:39-46.
Hildick-Smith D, Arunothayaraj S, Stankovic G, Chen SL.Percutaneous coronary intervention of bifurcation lesions. EuroIntervention. 2022; 18:e273-e291.
Albiero R, Burzotta F, Lassen JF, et al.Treatment of coronary bifurcation lesions, part I: implanting the first stent in the provisional pathway. The 16th expert consensus document of the European Bifurcation Club.EuroIntervention. 2022; 18:e362-e376.
Lassen JF, Albiero R, Johnson TW, et al.Treatment of coronary bifurcation lesions, part II: implanting two stents. The 16th expert consensus document of the European Bifurcation Club. EuroIntervention. 2022; 18:457-470.
Mori H, Torii S, Harari E , et al. Pathological mechanisms of left main stent failure. Int J Cardiol. 2018; 263:9-16.
Song YB, Hahn JY, Choi SH, et al.Sirolimus- versus paclitaxel-eluting stents for the treatment of coronary bifurcations results: from the COBIS (Coronary Bifurcation Stenting) Registry.J Am Coll Cardiol. 2010; 55:1743-50.
Zhang D, Xu B, Yin D, et al. How bifurcation angle impacts the fate of side branch after main vessel stenting: a retrospective analysis of 1,200 consecutive bifurcation lesions in a single center. Catheter Cardiovasc Interv. 2015; 85:706-15.
Lowe HC, Oesterle SN, Khachigian LM. Coronary in-stent restenosis: Current status and future strategies J Am Coll Cardiol. 2002; 39:183–193
De Filippo O, Kang J, Bruno F, et al.Benefit of Extended Dual Antiplatelet Therapy Duration in Acute Coronary Syndrome Patients Treated with Drug Eluting Stents for Coronary Bifurcation Lesions (from the BIFURCAT Registry). Am J Cardiol. 2021;156:16-23.
Hermiller JB.Bifurcation intervention: keep it simple. J Invasive Cardiol. 2006;18:43-4.
Ojeda S, Pan M, Mazuelos F, et al. Use of the venture wire-control catheter for accessing side branches during provisional stenting: an option for bifurcations with an unfavorable anatomy.Rev Esp Cardiol. 2010; 63:1487-91
Watanabe S, Saito N, Bao B, et al.Microcatheter-facilitated reverse wire technique for side branch wiring in bifurcated vessels: an in vitro evaluation.EuroIntervention. 2013; 9:870-7.
Chen SL, Zhang JJ, Han Y, et al. Double kissing crush versus provisional stenting for left main distal bifurcation lesions: DKCRUSH-V randomized trial. J Am Coll Cardiol. 2017; 70:2605-2617.
Khan M. Schmidt D. Bajwa T. et al. Coronary air embolism:incidence, severity, and suggested approaches to treatment.Cathet Cardiovasc Diagn 1995;36:313-8.
Dib J. Bolyle AJ. Chan M. et al. Coronary air embolism: a case report and review of literature. Catheter Cardiovasc Interv 2006; 68:897-900
Uppal S, DeCicco AE, Intini A, Josephson AR. Rapid Desensitization to Overcome Contrast Allergy Prior to Urgent Coronary Angiography. Int Heart J 2018; 59:622-625.
Brockow K, Christiansen C, Kanny G, et al. Management of hypersensitivity reactions to iodinated contrast media. Allergy 2005; 60:150–158.
