Coronary perforation incidence, outcomes and temporal trends (COPIT): a systematic review and meta-analysis

Abstract

Coronary perforation is a potentially life-threatening complication of percutaneous coronary intervention (PCI). We studied incidence, outcomes and temporal trends following PCI-related coronary artery perforation (CAP).MethodsProspective systematic review and meta-analysis including meta-regression using MEDLINE and EMBASE to November 2020. We included ‘all-comer’ PCI cohorts including large PCI registries and randomised controlled trials and excluding registries or trials limited to PCI in high-risk populations such as chronic total occlusion PCI or cohorts treated only with atheroablative devices. Regression analysis and corresponding correlation coefficients were performed comparing perforation incidence, mortality rate, tamponade rate and the rate of Ellis III perforations against the midpoint (year) of data collection to determine if a significant temporal relationship was present.Results3997 studies were screened for inclusion. 67 studies met eligibility criteria with a total of 5 568 191 PCIs included over a 38-year period (1982–2020). The overall pooled incidence of perforation was 0.39% (95% CI 0.34% to 0.45%) and remained similar throughout the study period. Around 1 in 5 coronary perforations led to tamponade (21.1%). Ellis III perforations are increasing in frequency and account for 43% of all perforations. Perforation mortality has trended lower over the years (7.5%; 95% CI 6.7% to 8.4%). Perforation risk factors derived using meta-regression were female sex, hypertension, chronic kidney disease and previous coronary bypass grafting. Coronary perforation was most frequently caused by distal wire exit (37%) followed by balloon dilation catheters (28%). Covered stents were used to treat 25% of perforations, with emergency cardiac surgery needed in 17%.ConclusionCoronary perforation complicates approximately 1 in 250 PCIs. Ellis III perforations are increasing in incidence although it is unclear whether this is due to reporting bias. Despite this, the overall perforation mortality rate (7.5%) has trended lower in recent years. Limitations of our findings include bias that may be introduced through analysis of multidesign studies and registries without pre-specified standardised perforation reporting CMore research into coronary perforation management including the optimal use of covered stents seems warranted.PROSPERO registration numberCRD42020207881.

Complications of PCI and its Management

“…In the CRACK registry data of covered stents for ELLIS 3 perforation complete sealing occurred in 83.2% but on 1-year follow-up had high risk of complications, cardiac death (7.1%), target lesion revascularisation (13.1%), myocardial infarction (MI) (11%), and ST in 6.1%. [14][15][16][17][18][19][20][21] e Glasgow Natural History Study of Covered Stent Coronary Interventions study was a 18-year period study of incidence and outcomes of coronary perforations from a single center. e incidence was 0.37% of PCI and Ellis Type III perforations occurred in 35% of the total perforations.…”

Understanding large vessel perforation requiring treatment with covered stent implantation: A case series

“…It is well documented that prompt treatment of large vessel perforation with balloon tamponade, often followed by covered stent implantation, can reduce the morbidity and mortality of these complications. 5,6 However, there is limited literature addressing the mechanism of these perforations. Large vessel tears are often anatomically complex and angiography may underestimate the severity or misidentify the inflow of the perforation leading to implantation of more than one covered stent to completely seal the leak.…”

“…It is well documented that prompt treatment of large vessel perforation with balloon tamponade, often followed by covered stent implantation, can reduce the morbidity and mortality of these complications 5,6 . However, there is limited literature addressing the mechanism of these perforations.…”

The PROGRESS‐CTO perforation risk score. Are you in?

“…This may represent different patterns in patient selection, practice, and aggressiveness during CTO‐PCI attempts. This 5% difference between only three cohorts may be even more marked across real‐world centers 1 . Therefore, the real‐world calibration remains uncertain despite good calibration statistics.…”

“…This 5% difference between only three cohorts may be even more marked across real-world centers. 1 Therefore, the real-world calibration remains uncertain despite good calibration statistics.…”