Early and Late Clinical Outcomes Following Coronary Perforation in Patients Undergoing Percutaneous Coronary Intervention.

Abstract

hile coronary perforation is an uncommon complication following percutaneous coronary intervention (PCI), [1][2][3][4][5][6][7][8] it is one that may lead to cardiac tamponade, 6-9 emergency coronary artery bypass surgery (CABG), or pseudoaneurysm formation, 10 with the potential for late coronary rupture. New coronary devices that resect (eg, directional or transluminal extraction atherectomy), ablate (eg, rotational atherectomy or excimer laser angioplasty), or score (eg, the cutting balloon) atherosclerotic plaque may increase the risk of coronary perforation, and a number of angiographic risk factors for its occurrence have been described previously. [11][12][13][14] The use of newer higher-weight and hydrophilic coronary guidewires may also increase the risk of coronary perforation, particularly during the treatment of chronic coronary occlusions. Clinical algorithms for the treatment of coronary perforation based on angiographic and clinical criteria have been Circulation Journal Vol.66, April 2002 less well studied. Moreover, descriptions of the long-term sequelae after coronary perforation, and delineation of the potential risk for late pseudoaneurysm formation and coronary rupture, have been lacking.The present study examines the frequency of coronary perforation during PCI, evaluates the management strategies used to treat the perforation, and describes the long-term prognosis in patients who have developed coronary perforation during PCI. To address these issues, we reviewed our experience with coronary perforation in a consecutive series of 7,443 patients undergoing PCI at a single, highvolume clinical center. Methods Patient PopulationBetween January 1992 and December 1996, 7,443 coronary interventional procedures were performed in the Cardiac Catheterization Laboratory at National Toyohashi Higashi Hospital. These procedures included conventional balloon angioplasty (n=4,895; 65.8%), cutting balloon angioplasty (n=1,274; 17.1%), coronary artery stenting (n=810; 10.9%), directional coronary atherectomy (DCA) (n=440; 5.9%), and transluminal extraction catheter atherectomy (n=24, 0.32%). Coronary perforation is a rare but serious complication that occurs during percutaneous coronary intervention (PCI). This study examines the frequency of coronary perforation during PCI, evaluates the management strategies used to treat perforations, and describes the long-term prognosis of patients who have developed coronary perforation during PCI. Coronary perforations were found in 69 (0.93%) of 7,443 consecutive PCI procedures, occurring more often after use of a new device (0.86%) than after use of balloon angioplasty (0.41%) (p<0.05).Coronary perforation was attributable solely to the coronary guidewire in 27 (0.36%) cases. Coronary perforations were divided into 2 types: (1) Those with epicardial staining without a jet of contrast extravasation (type I, n=51), and (2) those with a jet of contrast extravasation (type II, n=18). Patients with type I and type II perforations were managed by observation only (3...

Coronary Perforation During Percutaneous Coronary Intervention Lessons From Our Experiences

“…Previous reports have demonstrated that the increase in the risk of perforation is highly associated with the use of oversized balloons, 9) stenting against eccentric, extensive, or tortuous calcified lesions, 5,7,9) and the use of atherectomy devices. 2,3,6,8,9) In the patient series analyzed in this study, in addition to the other risk factors, the use of the sirolimus-eluting stent (SES) was also found to increase the incidence of coronary perforation. The SES has been available in Japan since 2004, and all 5 perforation events (2.69%) in 2004 and 2005 occurred after deployment of the SES or during wiring for crossing the lesion that was to be treated by the drug-eluting stent.…”

“…In such cases, lesion modification with rotational atherectomy prior to stenting and a gradual increase in the pressure for inflating the stent is recommended. Although debulking devices are known to increase the risk of perforation, 2,5,6,8) we believe that this is not the case when optimal-sized rotational atherectomy is used as a pretreatment for stenting. The selection of an undersized ablation device would be optimal in such cases since the main purpose of debulking is not to obtain sufficient lumen area but to modify the calcification, which causes difficulty in stent expansion.…”

“…[1][2][3][4][5][6][7][8] Fasseas, et al reported the incidence to be 0.58% in an analysis of 16,298 procedures carried out between 1990 and 2001.…”

“…reports have shown that the incidence of coronary perforation during PCI is 0.2% to 0.6%, [3][4][5][6][7][8] and the use of debulking devices is highly associated with this complication. 6) Despite a rapid increase in the incidence of this serious complication in recent years, 1,2,[4][5][6]9) definitive management of coronary perforation has not yet been established.…”

Crossing CTOs—The tips, tricks, and specialist Kit that can mean the difference between success and failure

“…If the degree of extravasation does not enlarge, or if it diminishes after this action, no further action is required. Should the extravasation enlarge, heparin reversal with protamine sulfate (1 mg per 100 units heparin) should be given intravenously, with subsequent dose titration guided by anticoagulation status (target activated clotting time <150 sec), [48,49]. Direct antithrombin agents such as bivalirudin are more problematical here as there is no simple antidote.…”