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

Abstract

Coronary perforation is a rare, but potentially catastrophic, complication of percutaneous coronary intervention. A retrospective review of the Cardiology Quality Assurance Database was performed for all percutaneous coronary interventions (n = 8,932) at William Beaumont Hospital from October 1988 to December 1992. Coronary artery perforation was reported in 35 patients (0.4%), including after percutaneous transluminal coronary angioplasty (PTCA, 11/7,905, 0.14%), transluminal extraction coronary atherectomy (TEC, 6/420, 1.3%), directional coronary atherectomy (DCA, 1/249, 0.25%), and excimer laser coronary angioplasty (ELCA, 5/242, 2%); and none after high-speed mechanical rotational atherectomy with the Rotablator (MRA, 0/116, 0%). Perforations were classified by coronary angiography as free perforations (n = 10), contained perforations (n = 17), or other types of perforation (n = 8). Although perforation was apparent in 32 (91%) of 35 angiograms, delayed cardiac tamponade occurred in 3 patients (9%), despite the absence of angiographic evidence for perforation at the time of the procedure. Causes of perforation were the guidewire in 7 (20%), an interventional device in 26 (74%), and indeterminate in 2 (6%). Complex B2 or C lesions accounted for 83% of perforations. Final treatment included conservative therapy (reversal of anticoagulation and/or PTCA) in 22 (63%) and surgical intervention (with or without bypass surgery) in 13 (37%). Serious clinical complications included cardiac tamponade in 6 (17%), blood transfusion in 12 (34%), myocardial infarction in 9 (26%), and death in 3 (9%).

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

“…11,14 As for new device use, coronary perforation has been reported to occur after 0.25-0.7% of DCA procedures, 11,14,[18][19][20] 0.0-0.7% of rotational atherectomy procedures, 14,21,22 1.3% of extraction atherectomy procedures, and 1.3-3.0% of excimer laser angioplasty procedures. [12][13][14] The present series showed that the incidence of coronary perforation was much higher than of previous reports. The higher rate may be attributable to the prevalence of chronic coronary occlusion interventions at the Institution.…”

“…While coronary perforations that are sealed within the catheterization laboratory have a benign prognosis, more severe perforations associated with cardiac tamponade may be associated with high morbidity and mortality. 13 In cases of severe coronary perforation, myocardial infarction rates occur in 16.7-50% 11,12,14 and death results in 9-19%. 11,12,14 In the present series, there were no in-hospital deaths associated with coronary perforation.…”

“…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.…”

Covered Stent Septal Ablation for Hypertrophic Obstruction Cardiomyopathy

“…2 Second, it raises the concern, especially with the use of GpIIb/IIIa inhibitor, that in the rare case of a side branch perforation after percutaneous coronary intervention in a patient in whom the bulky covered stent cannot be implanted in the side branch, covering the main branch may be ineffective in preventing tamponade, specifically because of the collateral, which in this scenario, is clearly not "protective." 3,4 Finally, we have a serious concern about the use of a covered stent to treat hypertrophic obstructive cardiomyopathy. There is probably a 20% risk of stent site stenosis, which, in the setting of hypertrophy, might place the patient at high risk for severe and possibly life-threatening ischemia.…”

Emergency polytetrafluoroethylene-covered stent implantation to treat right coronary artery perforation during percutaneous coronary intervention

“…Coronary artery perforation (CAP) is a rare but life-threatening complication of percutaneous coronary interventions (PCI) [1,2]. The incidence of CAP has been reported as 0.2-0.8% among all coronary interventions [3].…”