1) Perforations during CTO PCI occur in around 5.5% of cases and can involve the septum or epicardium. 2) Most septal perforations require no treatment and are managed with echocardiographic monitoring. 3) Epicardial perforations can be prevented by carefully selecting collaterals for retrograde crossing based on their shape. Treatment involves embolization of the perforation with coils or other materials. 4) Covered stents may also be used to treat epicardial perforations when embolization is not possible or fails.

1. Perforation management of
collaterals
Nicolas Boudou, MD
Clinique Saint - Augustin
Bordeaux

2. Potential conflicts of interest
Speaker's name: Dr Nicolas Boudou
 CTO proctoring: Terumo, Biotronik, Boston SC
 FORM A: score 2
 FORM B: score 2

3. Retrograde approach
Controlateral or ipsilateral
through septal collateral
through epicardial collateral
through CABG:
• Saphenous (patent or occluded)
• Arterial
Brilakis E. EuroIntervention 2016
McEntegart et al. EuroIntervention
2016;11
The collateral circulation of
coronary chronic total occlusions

5. A EL Sabbag et al. Int J Cardiol 174 (2014)243-48

7. • N= 1811 patients, consecutive CTO PCI
• 5 European centres, 2011- 2018
• Perforations: n=99 (5,5%)
• Tamponnade 0,9%
Azzalini L et al. Eurointervention 2019

8. Azzalini L et al. Eurointervention 2019

9. Coronary perforations

11. In most cases: no treatment  Haematoma inside
septum
• Echocardiography:
• Pericardial effusion : haematoma close to epicardium?
• Myocardial dysfunction induced by a large haematoma?
Septal perforation

12. Septal perforation
Asymptomatic  No treatment

13. Select interventional epicardial collateral suitable for retrograde crossing (low risk of damages)
r > d (r: Radius of a tortuosity > d :diameter of the collateral)  less risk of damages?
Guidewire  rotation > push
Epicardial perforation: prevention
r
d
d
r

14. Epicardial perforation: treatment

15. Embolization on both sides
• Angiographic analysis
• After collateral crossing
• if failure to cross collateral  embolization after CTO PCI success
Coïls, fat embolization
Epicardial perforation: treatment

16. • Microcatheters for CTO PCI +++
• Coïls 0,014’ : better if available with same microcatheter
• Ex: Helical coïls, Microvention Terumo (L 20mm, r 2mm)
• Fat embolization, thrombin…
• Covered stent
Shemisa K et al. Management of guidewire-induced distal coronary perforation using autologous
fat particles versus coil embolization. Catheter Cardiovasc Interv 2016
Epicardial perforation: treatment

17. Coïls
Coil name Manufacturer Description Detachment system
Axium Medtronic
Bare platinum coil with or without PGLA
or Nylon microfilaments enlaced
through the coil
Axium I.D.
(mechanical)
Hydrocoil (HES)
MicroPlex (MCS)
Microvention
HES: Bare platinum coil combined with
an expanding hydrogel polymer
MCS: Bare platinum coil with various
shapes and softness profiles
V-Grip
(thermo-mechanical)
Orbit
Cerecyte
Codman
Orbit: Bare platinum coil with various
shapes and
softness profiles
Cerecyte: Bare platinum coil with PGA
member within coil core
EnPower (thermomechanical)
Target Stryker
Bare platinum coil with various shapes
and softness profiles InZone (electrolytic)

18. Embolisation
- Coïls embolization through microcatheter Finecross
- In a small bifurcation
Ex: coïl embolization in epicardial perforation

19. Ex: covered stent in epicardial perforation

20. Ex: covered stent in epicardial perforation

21. Ex: covered stent in epicardial perforation
Ping Pong: reverse CART assisted with guide catheter extension

22. Ex: covered stent in epicardial perforation

23. Ex: covered stent in epicardial perforation
• Covered stent
• Pericardocentesis
• Reverse anticoagulation at the end