Coronary artery perforation during chronic total occlusion percutaneous coronary intervention: epidemiology, mechanisms, management, and outcomes

Abstract

Aims:The aim of this study was to describe the epidemiology, mechanisms, management, and outcomes of coronary artery perforation during chronic total occlusion (CTO) percutaneous coronary intervention (PCI). Methods and results:We included 1,811 consecutive patients undergoing CTO PCI at five centres between 2011 and 2018. Coronary perforation was observed in n=99 (5.5%). Patients with perforation were older, had a higher J-CTO score, more often required antegrade dissection/re-entry and the retrograde approach, and had lower success rates. The frequency of Ellis type I, II, III and III "cavity spilling" perforations was 11%, 46%, 28%, and 14%, respectively. In 48% of cases, perforation involved the CTO vessel, while the retrograde approach was responsible for 46% of cases. In 53% of cases perforations required intervention. The most frequently applied management strategies included clinical observation (47%), covered stent implantation (25%), balloon occlusion (9%), and coil/fat embolisation (9%). Tamponade was observed in 20/99 (20%) perforation cases. Ellis type III perforations were most frequently observed at the CTO site. These were accountable for 16/20 tamponades and 3/5 deaths. In-hospital mortality was 5.1% vs 0.3% in patients with versus those without perforation (p<0.001). Older age, occlusion length >20 mm, rotational atherectomy, antegrade dissection/re-entry, and the retrograde approach were independently associated with coronary perforation. Patients with perforation suffered an increased incidence of target vessel failure on short-term follow-up.Conclusions: Coronary perforation is observed in a non-negligible proportion of CTO PCIs, often requires intervention, and is associated with tamponade and mortality in a minority of patients. CTO vessel-related perforations are associated with the highest burden of morbidity and mortality.

Prognostic significance of occlusion length in recanalized chronic total occlusion lesion: a retrospective cohort study with 5-year follow-up

“…Subintimal tracking and vessel injury seemed to be developed inevitably when management of complex CTO lesion. [21][22][23][24] Some studies showed that extensive subintimal stenting and target vessel injury increased the chance of revascularisation. 24 25 Recent studies evaluated the role of occlusion length on the outcomes of successful CTO PCI, 26 27 however, there are still some questions needed to be answered.…”

Complications of chronic total occlusion percutaneous coronary intervention

“…In a recently published analysis of 1811 cases from five European centres it occurred in 5.5% of the CTO PCIs, with more than half of these cases requiring management and 20% resulting in tamponade. The following characteristics were found to be independently associated with coronary perforation: older age, occlusion length >20 mm, rotational atherectomy, antegrade dissection/re-entry, and use of the retrograde approach [9]. In another multicentre US registry analysing 2097 CTO PCIs performed in 2049 patients, the incidence of perforation was 4.1%, with 14% of the patients developing tamponade requiring pericardiocentesis.…”

Retrograde Access to Seal a Large Coronary Vessel Balloon Perforation Without Covered Stent Implantation

“…Coronary perforation is the Achilles’ heel of chronic total occlusion (CTO) percutaneous coronary intervention. It occurs in approximately 6% of CTO procedures and is associated with a high risk for periprocedural death ( 1 ). By convention, sealing a coronary perforation requires the deployment of one or more covered-stents (CSs).…”