Management and Outcomes of Coronary Artery Perforation During Percutaneous Coronary Intervention

doi:10.1016/j.amjcard.2006.04.032

The American Journal of Cardiology

Volume 98, Issue 7, 1 October 2006, Pages 911-914

https://doi.org/10.1016/j.amjcard.2006.04.032 Get rights and content

Coronary perforation is a particularly feared complication of percutaneous coronary intervention. The optimal management and predictors of adverse outcomes for these patients remain to be defined. Advances in management such as the use of polytetrafluoroethylene-covered stents have not been critically examined in terms of efficacy. We analyzed a cohort of patients who sustained coronary perforation during percutaneous coronary intervention at our institution during a 9-year period to examine the trends in incidence, management, and outcomes. The patient medical records were reviewed, and detailed angiographic analysis was undertaken to identify the predictors of adverse outcomes, including the development of tamponade, the requirement for emergency coronary artery bypass grafting, and in-hospital death. One year of follow-up was attempted for all patients. Seventy-two cases of coronary perforation were identified, with an overall incidence of 0.19%. The perforation grade and presence of chronic renal insufficiency were the only predictors of mortality on multivariate regression analysis. The use of polytetrafluoroethylene-covered stents to manage perforations was not associated with any reduction in adverse outcomes, such as the development of tamponade, the need for emergency coronary artery bypass grafting, or in-hospital death. In conclusion, coronary perforation remains a feared complication in the contemporary interventional era with significant in-hospital mortality. Emphasis should be placed on preventing this complication whenever possible, including exercising particular caution in patients with chronic renal insufficiency. The treatment of such patients should be tailored to the severity of the perforation. The optimal treatment of these patients needs to be defined, and the efficacy of covered stents needs to be studied prospectively.

Section snippets

Patient population

All patients who had a coronary perforation as a complication of PCI during a 9-year period from May 1996 to May 2005 were identified retrospectively from the PCI database at our institution. A detailed chart review was done, and angiographic analysis was then undertaken. A standardized questionnaire was used for data collection. The clinical variables, procedural information, and outcomes were obtained from chart review. The angiographic characteristics were obtained from angiographic analyses

Incidence

A total of 72 cases of coronary perforation were identified during a 9-year period of a total of 38,559 interventions, for an incidence of about 0.19%. In the era of drug-eluting stent implantation (since March 2004), 17 cases occurred from a total of 10,896 interventions, for an incidence of 0.15%. The baseline clinical characteristics are outlined in Table 1. The average age of the patients with a coronary perforation was 68.5 ± 11.2 years (range 33 to 91), and 68% were men.

Angiographic characteristics and procedural information

The angiographic

Discussion

The results of this study have illustrated the institutional experience with coronary perforations at an extremely high-volume center during a 9-year period in an era when interventional cardiology evolved dramatically. There was a 25% decrease in the incidence of coronary perforation in the current drug-eluting stent era compared with interval immediately preceding the current era. The incidence rates compare favorably with those from recent studies by Witzke et al¹⁶ and Ramana et al⁶

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Rotational Atherectomy Complicated by Coronary Perforation Is Associated With Poor Outcomes: Analysis of 10,980 Cases From the British Cardiovascular Intervention Society Database
2021, Cardiovascular Revascularization Medicine
Rotational atherectomy (RA) during PCI is linked to a higher likelihood coronary perforations (CP). However, the evidence base on incidence, predictors and outcomes of this complication in RA-PCI remains limited.
Using the British Cardiac Intervention Society database, data were analysed on all RA-PCI procedures in UK 2007–2014. Descriptive statistics and multivariate logistic regressions were used to examine baseline, procedural and outcome associations.
During 10,980 RA-PCI procedures, 167 CPs were recorded (1.52%) with a stable annual incidence. Baseline and procedural covariates associated with higher rates of RA perforation were number of stents used, female gender, smoking, and left-main stenosis. CP was significantly associated with shock, DC cardioversion, heart block, transfusion, emergency surgery, periprocedural MI, in-hospital major bleed, acute kidney injury, dissection, side branch loss and in-hospital death. CP was also associated with higher rates of in-hospital MACCE (OR 12.22, 95% CI 7.67–19.47), 30-day mortality (OR 10.02, 95% CI 5.87–17.09) and 12-month mortality (OR 3.90, 95% CI 2.53–6.02).
CP is more frequent in RA-PCI than all-comer PCI and is associated with a significant burden of morbidity and mortality. There are a limited number of baseline and procedural co-variates associated with CP in RA-PCI, making it difficult to predict.
Incidence, Management, Immediate and Long-Term Outcome of Guidewire and Device Related Grade III Coronary Perforations (from G3CAP - Cardiogroup VI Registry)
2021, American Journal of Cardiology
Ellis grade III coronary artery perforations (G3-CAP) remain a life-threatening complication of percutaneous coronary intervention (PCI), with high morbidity and mortality and lack of consensus regarding optimal treatment strategies. We reviewed all PCIs performed in 10 European centers from 1993 to 2019 recording all G3-CAP along with management strategies, in-hospital and long-term outcome according to Device-related perforations (DP) and Guidewire-related perforations (WP). Among 106,592 PCI (including 7,773 chronic total occlusions), G3-CAP occurred in 311 patients (0.29%). DP occurred in 194 cases (62.4%), more commonly in proximal segments (73.2%) and frequently secondary to balloon dilatation (66.0%). WP arose in 117 patients (37.6%) with chronic total occlusions guidewires involved in 61.3% of cases. Overall sealing success rate was 90.7% and usually required multiple maneuvers (80.4%). The most commonly adopted strategies to obtain hemostasis were prolonged balloon inflation (73.2%) with covered stent implantation (64.4%) in the DP group, and prolonged balloon inflation (53.8%) with coil embolization (41%) in the WP group. Procedural or in-hospital events arose in 38.2% of cases: mortality was higher after DP (7.2% vs 2.6%, p = 0.05) and acute stent thrombosis 3-fold higher (3.1% vs 0.9%, p = 0.19). At clinical follow-up, median 2 years, a major cardiovascular event occurred in one-third of cases (all-cause mortality 8.2% and 7.1% respectively, without differences between groups). In conclusion, although rare and despite improved rates of adequate perforation sealing G3-CAP cause significant adverse events. DP and WP result in different patterns of G3-CAP and management strategies should be based on this classification.
Contemporary Trends, Predictors and Outcomes of Perforation During Percutaneous Coronary Intervention (From the NCDR Cath PCI Registry)
2020, American Journal of Cardiology
Coronary artery perforation (CP) is a rare but potentially life-threatening complication of percutaneous coronary intervention (PCI). Given the marked increase in high-risk and complex PCIs, careful review and understanding of PCI complications may help to improve procedural and clinical outcomes. Our aim was to study the trends, predictors and outcomes of CP in the contemporary era. This cross-sectional multicenter analysis included data collected from institutions participating in the National Cardiovascular Data Registry CathPCI Registry between July 2009 and June 2015. Multivariable logistic regression models were created to identify predictors of CP and compare the in-hospital outcomes of CP and non-CP patients. Of 3,759,268 PCIs performed during the study period, there were 13,779 CP (0.37%). During the study period, the proportion of PCI that developed CP remained unchanged (0.33% to 0.4%) (p for trend 0.16). Chronic total occlusion (CTO) PCI as percentage of total PCI volume increased over the study period (3% to 4%) (p for trend <0.001) with a concomitant significant increase in CTOs with perforation (1.2% to 1.5%, p for trend = 0.02). CTO PCI (Odds Ratio [OR] 2.59) female gender (OR 1.38), saphenous vein graft PCI (OR 1.2), ACC Type C lesion (1.48), cardiogenic shock on presentation (1.15), and use of atherectomy (laser/ rotational) (OR 2.38) were significant predictors of CP. CP patients had significantly higher rates of cardiogenic shock (7.73% vs 1.02%), tamponade (9.6% vs 0.05%) and death (4.87% vs 1.14%) compared with those without CP. Strongest predictors of any adverse events amongst CP were cardiogenic shock (OR 3.93), cardiac arrest (OR 2.02) and use of atherectomy device (OR 2.5). Use of covered stents was also strongly associated with adverse events (OR 3.67) reflecting severity of these CPs. CP in CTO PCI had higher rates of any adverse event than non-CTO CP (26.8% vs 22%, p < 0.001). However non-CTO CP had higher rates of coronary artery bypass grafting (CABG) (urgent, emergent, or salvage) (5.8% vs 4.5%, p = 0.03) and death (6.9% vs 5.6%, p = 0.04). CP in CABG PCI had fewer adverse events compared with those without previous CABG (16.1% vs 24.7%). In a large real world experience, we identified several clinical and procedural factors associated with increased risk of CP and adverse outcomes. The trends in CP remained constant over the study period.
Outcomes of Percutaneous Antegrade Intraluminal Coronary Intervention of Chronic Total Occlusion With Remote Surgical Backup
2019, Current Problems in Cardiology
Percutaneous coronary intervention (PCI) of chronic total occlusion (CTO) is not favored in facilities without on-site surgical backup. We reviewed outcomes of patients who had CTO intervention with remote surgical backup in our institution. All patients who underwent attempted antegrade intraluminal CTO PCI from January 2013 to July 2017 were analyzed. Twenty cases (18 patients, 58.1 ± 7.0 years, 70% males) were identified. Procedure was successful in 85% (17 of 20). There were 2 nonflow limiting dissections and 1 wire perforation. Two patients had post-PCI myocardial infarction. There was no cardiac death, myocardial infarction, target vessel revascularization, or stroke at 30 days and at mean follow-up of 19.5 ± 13.7 months. There were 4 rehospitalizations for angina requiring repeat angiogram in 3 cases: 2 without intervention, and 1 referred for coronary artery bypass grafting. Careful attempt at antegrade intraluminal CTO intervention done at a center with remote surgical backup is feasible in selected patients.
“Incidence, clinical and angiographic characteristics, management and outcomes of coronary artery perforation at a high volume cardiac care center during percutaneous coronary intervention”
2020, Indian Heart Journal
To study the incidence, clinical and angiographic characteristics, management and outcomes of coronary artery perforation (CAP) during percutaneous coronary intervention (PCI) at a high volume center in South-east Asia.
Data from patients who had CAP during PCI from January 2016 to December 2019 at our center were collected. Clinical features, angiographic and procedural characteristics, their management and outcomes were analyzed retrospectively.
A total of 40,696 patients underwent PCI during the study period and the incidence of CAP was 0.13% (n = 51). Mean age was 60.0 ± 10.8 years and 69% were males. CAP cases involved complex type B2/C lesions in 73%, calcified lesions in 58%, and chronic total occlusions in 25%. Majority of patients presented as acute coronary syndrome (65%) and STEMI was the most frequent indication for PCI (33%). Most of the CAPs were Ellis type II (33%) and III (55%). CAP most frequently occurred during post dilation (n = 20) and wire manipulation (n = 17). Majority were treated by prolonged balloon inflation (53%) and covered stents (33%). Pericardiocentesis was required in 19 patients to alleviate tamponade. In one patient coil embolisation was done and two patients required bail-out emergency cardiac surgery. Periprocedural myocardial infarction occurred in 6% and in-hospital mortality was 10%. All-cause mortality accrued to 14% at 30 days and 16% at 6 months.
Although incidence of CAP in contemporary interventional practice remains low, the morbidity and mortality are considerable. Early recognition and management strategies tailored to the severity of perforation play a key role in achieving better outcomes.
A Novel Closed-Loop Balloon-Stent Embolization for the Treatment of Coronary Artery Perforation
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Regular paperManagement and Outcomes of Coronary Artery Perforation During Percutaneous Coronary Intervention

Section snippets

Patient population

Incidence

Angiographic characteristics and procedural information

Discussion

J Am Coll Cardiol

Am J Cardiol

Am J Cardiol

Am J Cardiol

Perforations after percutaneous coronary interventions: clinical, angiographic, and therapeutic observations

Cathet Cardiovasc Diagn

Increased coronary perforation in the new device era: incidence, classification, management, and outcome

Circulation

Coronary artery perforation during percutaneous intervention: incidence and outcome

Heart

Coronary artery perforation during percutaneous coronary intervention: incidence and outcomes in the new interventional era

J Invasive Cardiol

Regular paper
Management and Outcomes of Coronary Artery Perforation During Percutaneous Coronary Intervention