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A Novel Percutaneous Technique for Coaxial Treatment of Large Coronary Vessel Perforations-The RIP (Rip and Inflate
Maximilian Will1, Konstantin Schwarz1, Gregor Leibundgut2
1Department of Internal Medicine 3, University Hospital St. Pölten-NOE LGA, Karl Landsteiner University, Dunant-Platz 1, 3100 St. Pölten, Austria.
Insights
A new Rip and Inflate in Perforations (RIP) technique simplifies managing coronary artery perforations during percutaneous coronary intervention (PCI). This method uses a single guide catheter, avoiding complex maneuvers and extra vascular access needed with the ping-pong technique.
Area of Science:
- Interventional Cardiology
- Vascular Surgery
- Medical Device Technology
Background:
- Coronary perforations during percutaneous coronary intervention (PCI) are rare but life-threatening.
- Current management, like the ping-pong technique, is complex and requires multiple vascular access sites.
- A simplified technique is needed to manage these complications effectively.
Purpose of the Study:
- To introduce a novel technique for sealing coronary artery perforations during PCI.
- To enable covered stent implantation using a single guide catheter.
- To reduce procedural complexity and the need for additional vascular access.
Main Methods:
- A guide extension catheter (GEC) is advanced across the perforation after balloon inflation and hypotube detachment.
- A coronary wire introducer needle attached to the hypotube minimizes leakage during GEC advancement.
- The technique was validated through bench testing and applied in three clinical cases.
Main Results:
- Bench testing confirmed the technique's reproducibility and feasibility.
- The GEC was successfully advanced across perforations in all three clinical cases.
- Covered stents were deployed efficiently using a single guide catheter and access site without failure.
Conclusions:
- The Rip and Inflate in Perforations (RIP)-technique is a feasible and reproducible alternative to the ping-pong technique.
- This novel method simplifies the management of large-vessel coronary perforations.
- The RIP-technique reduces procedural complexity and the need for additional vascular access.
Abstract:
Background/Objectives: Coronary perforations are infrequent but potentially fatal complications during percutaneous coronary intervention (PCI). Interventional management aims to stop extravasation and restore distal flow to prevent tamponade and cardiogenic shock. In current practice, the ping-pong technique is recommended to ensure sealing of the perforation during covered stent delivery. However, this method is complex, time-consuming, and requires a second vascular access. Therefore, we developed a technique that seals the perforation and enables covered stent implantation using a single guide catheter. Methods: This technical note describes a novel technique in which a guide extension catheter (GEC) can be advanced across a vascular perforation after balloon inflation. The insertion of the GEC is made possible by detachment of the balloon hypotube. To minimize leakage, a regular coronary wire introducer needle is attached to the snapped hypotube after GEC loading and continuously inflated to hold nominal pressure. Advancement of the GEC across the perforation immediately limits hemorrhage and facilitates covered stent deployment via a single vascular access. The technique was first evaluated in bench testing and subsequently applied in three illustrative clinical cases at a tertiary referral center using standard, commercially available devices. Results: Bench testing confirmed the reproducibility of the ripping maneuver and successful ballon inflation over enough time to advance the GEC with the introducer married with the ripped hypotube. In all clinical cases, the GEC was successfully advanced across the perforation, allowing prompt covered stent deployment where necessary using a single guide catheter and access site without technical failure. Conclusions: The RIP (Rip and Inflate in Perforations)-technique is a feasible and reproducible alternative to the ping-pong technique. Bench validation and initial clinical application suggest that it may simplify the management of large-vessel perforations while reducing procedural complexity and the need for additional vascular access.
