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 Table of Contents  
Year : 2021  |  Volume : 7  |  Issue : 3  |  Page : 230-235

A detailed review of management of coronary perforations by gelfoam closure

Department of Cardiology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India

Date of Submission02-Jul-2021
Date of Decision12-Nov-2021
Date of Acceptance13-Nov-2021
Date of Web Publication14-Dec-2021

Correspondence Address:
Debasish Das
Department of Cardiology, All India Institute of Medical Sciences, Bhubaneswar - 751 019, Odisha
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jpcs.jpcs_45_21

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We report a rare case of inadvertent distal small diagonal branch perforation noted postleft anterior descending coronary artery revascularization, rescued by Gelfoam closure in a 43-year diabetic male presenting with acute anterior wall ST elevated myocardial infarction. Intermittent balloon inflation for 30 min was not able to seal off the perforation; because of impending late (3–6 h) cardiac tamponade, we closed the perforation with Gelfoam embolization through Caravel microcatheter. Although rarely practiced, this armamentarium should be there in the interventional cardiology laboratory to deal with small vessel perforation (<2 mm), for which traditionally covered stents are not available in size.

Keywords: Closure, coronary perforation, Gelfoam

How to cite this article:
Das D, Acharya D, Singh J, Pramanik S. A detailed review of management of coronary perforations by gelfoam closure. J Pract Cardiovasc Sci 2021;7:230-5

How to cite this URL:
Das D, Acharya D, Singh J, Pramanik S. A detailed review of management of coronary perforations by gelfoam closure. J Pract Cardiovasc Sci [serial online] 2021 [cited 2023 Mar 30];7:230-5. Available from: https://www.j-pcs.org/text.asp?2021/7/3/230/332490

  Introduction Top

Hydrophilic and stiff coronary wires, although possess the ease of crossability, have the indigenous disadvantage of passing inadvertently into small distal coronary branches during difficult crossing with balloons and stents without eventual notice of the operator. While in the distal branch, those hydrophilic wires such as Runthrough and Feilder FC, designated chronic total occlusions wires such as Fielder XT and Fielder XT-A, and Gaia group of wires produce perforation even with slightly harder forward push. The conventional workhorse wire-like balanced middle weight (BMW) wire is not so frequently known to cause coronary artery perforation (CAP). Large branch perforation is a catastrophe in the intervention laboratory with hemodynamic instability and the need for an urgent deployment of a covered stent with immediate pericardial drainage. Small branch perforations (<2 mm) pose a particular challenge as covered stents of 2 mm size are usually not available, it is difficult to negotiate the high profile and less flexible covered stent into small branches, and intermittent balloon inflation quite often fails to seal off the perforation. Bleeding into the pericardial space from small vessel perforation is a slowly accumulating process with a late presentation in cardiac tamponade 3–6 h postprocedure. We report a rare case of inadvertent distal diagonal branch perforation by Fielder FC wire during revascularization of the left anterior descending (LAD) artery which was closed by Gelfoam as balloon tamponade for 30 min could not seal off the diagonal perforation.

  Case Top

A 43-year-old male diabetic, nonhypertensive, nonsmoker presented with acute-onset retrosternal chest discomfort since last 8 h with shortness of breath New York Heart Association Class III, electrocardiogram (EKG) revealed anterior wall ST elevated myocardial infarction with moderate left ventricular systolic dysfunction with ejection fraction of 38%. He was taken for primary percutaneous intervention. Mid LAD harbored type C lesion with eccentric dense calcification [Figure 1]. Fielder FC wire was used as the first wire of choice to cross the lesion because of dense calcification. The lesion was crossed with 0.014 Fielder FC wire and dilated with a semi-compliant 1.25 mm × 8 mm NIC Nano balloon followed by a 1.5 mm × 10 mm semi-compliant balloon. The difficulty arose while crossing the occluded segment with a 2 mm × 10 mm semi-compliant balloon; the operator deployed moderate force to cross the segment. The segment was dilated at 16 atm pressure and a drug-eluting stent of 2.75 mm × 28 mm was deployed across the lesion at 14 atm pressure. Post deployment, the patient got distal thrombolysis in myocardial infarction III flow, but immediately, he had bradycardia with heart rate (HR) of 42 beats per min, but blood pressure (BP) was within the normal limit of 102/64 mmHg. Due to possible vasovagal reaction, he was asked to cough, 500 ml normal saline was infused in 30 min, and IV atropine was administered. However, the patient's bradycardia did not improve to a significant extent, with a persistent HR around 52–56 beats per min. Another possible cause of persistent bradycardia was bleeding into the pericardial space causing irritation of inferior diaphragmatic surface and inciting Bezold–Jarisch Reflex. Left coronary was injected and long cine revealed perforation of a small distal diagonal branch [Figure 2], [Figure 3], [Figure 4]. It was wired with routine BMW wire [Figure 5] to avoid bias during the intervention, and it is always recommended to exchange the hydrophilic wire with workhorse wire during the intervention of coronary perforation. Slightly more curve was given to the BMW wire tip to negotiate the diagonal angle, and proximal balloon inflation was opted to seal off the perforation with a 1.5 mm × 8 mm semi-compliant balloon [Figure 6] at 14 atm pressure for each session of 5–10 min with an intermittent release. Heparin was reversed with 50 IU of intravenous protamine. After 30 min of balloon inflation, repeat coronary injection revealed that the perforation was not sealed off. It was decided to stop the bleeding from the perforation with an injection of Gelfoam into the diagonal branch proximal to the site of perforation so that it will be completely thrombosed, scarifying the distal territory with small infarct. While parking the wire most distal in the diagonal branch, a 4F Caravel microcatheter was negotiated till the proximal part of the perforation in the diagonal branch [Figure 7]. Gelfoam sponge was obtained from lower peripheral intervention laboratory, foam particles were prepared by rubbing its inclined surface with the sharp edge of a sterile BP, it was mixed with 5 cc contrast for 30 s, a three-way cannula was attached to the back of the Caravel microcatheter, and 2cc of the prepared Gelfoam was precisely injected into the diagonal branch proximal to the perforation site, 5 min was allowed for the Gelfoam to form a thrombus after which the coronary was injected again which revealed complete occlusion from the thrombosed middle part of the diagonal branch with sealed off perforation [Figure 8]. Interestingly, the patient's HR post Gelfoam embolization accelerated, EKG revealed deepening of T wave inversion in lateral leads due to induced small infarct in the sacrificed distal diagonal territory. The patient was managed as periprocedural myocardial infarction with low molecular weight heparin in addition to conventional dual antiplatelets, high-dose statin, and anti-failure medications. This case of small vessel coronary perforation was sealed with Gelfoam; otherwise, slow and continuous bleeding from the diagonal may have landed in a catastrophic tamponade after 3–6 h. Deep T wave inversion in the patient's EKG normalized after 24 h and he was uneventfully discharged from the hospital after 3 days.
Figure 1: Subtotal calcific lesion in mid LAD.

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Figure 2: Perforation in distal diagonal branch.

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Figure 3: Ellis Grade II perforation.

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Figure 4: Contrast staining of the myocardium.

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Figure 5: Wiring the diagonal with BMW wire.

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Figure 6: 1.5 mm × 8 mm balloon inflation.

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Figure 7: Caravel microcatheter in diagonal branch delivering Gelfoam.

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Figure 8: Sealed off coronary perforation in diagonal after Gelfoam embolization.

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  Discussion Top

Small distal vessel perforations are usually closed by prolonged balloon inflation or embolization of Gelfoam or thrombogenic metallic coils. The current recommendation of perforated coronary arteries involves the use of prolonged balloon inflation or the use of covered stents. Covered stents are available from the diameter of 2–2.25 mm.[1] It poses a great challenge when a vessel <2 mm perforates with a risk of late tamponade after 3–6 h. CAP in small vessels <2 mm in diameter is managed with autologous clot or fat,[2],[3] Gelfoam,[4] fibrin glue,[5] microcoils,[6] and polyvinyl alcohol embolization[7],[8],[9],[10],[11],[12],[13] to provide hemostasis and bleeding cessation. CAP is a rare but serious complication of percutaneous coronary intervention and may cause cardiac tamponade, myocardial infarction, and death. Perforation occurs in 0.1%–0.4% of patients undergoing balloon angioplasty[14],[15],[16],[17],[18],[19] but is more frequent with newer interventional devices, including rotational atherectomy, transluminal extraction coronary atherectomy, directional atherectomy, and excimer laser angioplasty.[20],[21],[22] Dixon et al.[4] reported a case of perforation of distal intermediate artery presenting with cardiac tamponade 3 h after angioplasty, the patient was mechanically ventilated and the vessel was sealed off with two pieces of Gelfoam embolization mixed with contrast. In their description, balloon occlusion for 25 min was also not successful to seal off the perforation. A fair try of balloon occlusion for 30 min was tried in this case, after which Gelfoam embolization was carried out. During balloon angioplasty, CAP occurs due to guidewire-induced perforation in up to 20% of cases,[19] oversizing of the balloon or balloon rupture may also induce perforation. New guidewires with hydrophilic coating (Fielder FC, Fielder XT, Fielder XT A, Whisper Choice Floppy wire), stiffer wires (wire of Gaia family) or wire with tapered tip increases the likelihood of chronic total occlusion crossing at the cost of more vessel perforation.[23] Most cases of coronary perforation become evident immediately, delayed presentation is also well recognized.[24] Angiographic appearance of perforation varies from a myocardial blush (Grade 1) to frank contrast extravasation (Type III). Thomas et al. also described successful Gelfoam coil embolization of perforated coronary artery.[25] There is less information on the treatment of distal vessel guidewire perforation which usually occurs in small distal branches, as noted in our case; besides Gelfoam vessel occlusion, microcoil embolization has also been reported.[6],[26] Gelfoam is absorbable gelatin available in both powder and sponge form. Gelfoam available in the sponge form was used in this case. A sterile BP blade was used to shave the surface of the sponge to generate Gelfoam powder and it was mixed with 5 cc of contrast and 2 cc was taken out of that. Foam was prepared with another 5cc syringe attached to a three-way stop cock and it was delivered through the Caravel microcatheter proximal to the point of perforation in the diagonal branch. Gelfoam hastens clot formation and also provides structural support to the clot.[27] The only important thing is sufficient duration should be allowed for Gelfoam to thrombose and seal small perforation site. Gelfoam is even effective in controlling life-threatening hemorrhage,[28] used for hepatic artery embolization for primary and metastatic liver tumors,[29],[30] to treat catheter-induced pulmonary artery pseudoaneurysms[31] and ureteric and bronchoesophageal fistula.[32],[33] Our report describes a rare practice of sealing guidewire-induced CAP using Gelfoam injected through a microcatheter into the coronary artery proximal to the point of perforation. In small distal bed coronary perforation, Gelfoam has a useful clinical role, all interventional cardiology laboratories should be equipped with it to treat this uncommon emergency. Echocardiography should be performed as soon as perforation is identified. If pericardial hemorrhage or hemodynamic collapse occurs, pericardiocentesis should be performed immediately with multiple side holes for continuous aspiration, after which the drain should be kept in place for 6–24 h.[34] Rapid infusion of intravenous normal saline is recommended, a minimum of 1 l in 1 h or 500 ml in 30 min should be administered. A balloon of 1:1 diameter of the vessel size should be immediately placed with inflations lasting up to 5–10 min. If the perforation does not seal, repeated inflation should be made. Distal ischemia is of concern in the main vessel where a perfusion balloon can be used without blocking distal blood flow. However, many laboratories lack perfusion balloons to do the same. Reversal of anticoagulation can be achieved with protamine. As previously shown, the use of protamine is safe and does not predispose to stent thrombosis.[35],[36] Diabetic patients on protamine-containing insulin and patients with fish allergy are at increased risk for protamine reactions. GP IIb/IIIa inhibitors should also be discontinued and platelet transfusions should be used if needed. If a large perforation causes severe ischemia or hemodynamic deterioration or cannot be sealed with the available techniques, emergency surgery is indicated. Surgical intervention may be life-saving, but, since these patients have more severe perforations, it is associated with higher morbidity and mortality and worse outcome. Earlier surgical referral should be considered in this context when dealing with high-grade perforations.[37] Trehan et al. described perforation of a small ventricular branch of the right coronary artery which was successfully occluded by packing it with pieces of thrombogenic floppy tips of used coronary angioplasty guidewires instead of conventional metallic coils.[38] Delivery of the coronary angioplasty guidewires requires larger size microcatheters, while the delivery of Gelfoam or fat particle can be accomplished with smaller microcatheters. Li et al. described silk suture embolization of two cases of guidewire-induced distal CAP.[39] To et al. described successful closure of a coronary perforation in a 76-year-old male with tri-acryl gelatin microsphere embolization.[40] Deb et al. described the role of Gelfoam closure in collateral perforation.[41] Hashemi et al. described the closure of a coronary perforation in diagonal with “Spongostan,” a form of Gelfoam used by ear, nose, and throat surgeons.[42] Vakili et al. described Gelfoam closure as a reasonable way of closure of coronary perforation noted after guidewire removal.[43] Mishra et al. described successful closure of Ellis type III LAD coronary perforation with cyanoacrylate glue.[44] Lim et al. described successful closure of a distal wire induced first diagonal perforation managed with <0.5 mm Gelfoam.[45] Dash et al. described Gelfoam, clotted autologous blood, thrombin, and polyvinyl alcohol are also useful alternatives during the bailout of chronic total occlusion intervention.[46] Dash described perforations in small or distal vessels not resolving with balloon occlusion can be managed by coil or Gelfoam embolization.[47] Mehrotra and Vijayvergiya described autologous clotted blood in place of Gelfoam as effective in sealing and healing of side branch perforation.[48] Before proceeding for Gelfoam embolization, one should try for balloon occlusion first, which may seal the perforation. Guidewire-induced distal small vessel perforation should be appropriately managed with Gelfoam or coil-induced complete thrombosis of the vessel proximal to the point of perforation in the event of failure of balloon inflation, which seals off the continuous bleeding into the pericardial space to prevent the development of catastrophic tamponade. Gelfoam embolization rescues the patient from the most common nightmare of guidewire-induced coronary perforation in the intervention laboratory.

  Conclusion Top

We describe a rare of guidewire-induced distal small vessel coronary perforation closed with Gelfoam which saved the patient from late-onset cardiac tamponade; in time, sealing of the coronary perforation is the key to achieving a good periprocedural outcome. The art of Gelfoam embolization is quite simple when delivered through a microcatheter, and interventional laboratories dealing with complex coronaries should have the same in their armamentarium to rescue the patient from an uncommon emergency like coronary perforation.

Ethics clearance

Institutional Ethical Committee (IEC) Clearance has been obtained.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]

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