Coronary artery perforation during percutaneous intervention: incidence and outcome

Abstract

Objective: To examine the clinical outcome of percutaneous coronary intervention where the procedure was complicated by vessel perforation. Setting: Tertiary referral centre. Methods: The procedural records of 6245 patients undergoing coronary intervention were reviewed. In 52 patients (0.8%) the procedure was complicated by vessel perforation, ranging from wire exit to free flow of contrast into the pericardial space. The majority of lesions treated were complex (37% type B, 59% type C) and 9 of 52 (17%) were chronic occlusions. Ten patients (19%) received abciximab. Four underwent rotational atherectomy (8%). Results: In 28 of 52 patients (54%) the perforation was benign and managed conservatively without the development of haemodynamically significant sequelae. In 24 of 52 (46%) a significant pericardial effusion ensued requiring drainage. Of these 24 procedures 6 had involved the treatment of a chronic occlusion (25%). Eight of the 24 patients were referred for emergency bypass surgery (33%), 3 of whom died. Of the remaining 16 not referred for surgery, 3 died. Of the 10 procedures complicated by vessel perforation where abciximab had been administered, 9 (90%) led to pericardial tamponade. Latterly 2 vessel perforations were successfully treated by the deployment of a covered stent. Conclusions: Coronary artery perforation with sequelae during intervention is rare-26 of 6245 (0.4%). This complication was seen in the treatment of chronic occlusions, which are therefore not riskfree procedures. The development of pericardial tamponade carries a high mortality. While prompt surgical intervention may be life saving, expertise in the use of covered stents may provide a valuable rescue option for this serious complication. Caution should be exercised where coronary perforation occurs and abciximab has been used. V essel perforation during or following percutaneous coronary intervention (PCI) is a rare complication of this procedure. Previous reports cite an incidence of between 0.2-0.6% 1-6 and while some of these series were reported during the era of balloon angioplasty alone, more recent studies have referred to intervention using newer devices including stents and rotational and directional atherectomy. Not all authors have included the full spectrum of pathology in their definition of vessel perforation. This may range from mere vessel puncture by the guidewire resulting in minimal dye staining without adverse haemodynamic consequences, to "wire exit", to vessel rupture followed by brisk extravasation of blood and dye into the pericardial space leading to tamponade and abrupt haemodynamic collapse.As the range of equipment available to the interventional cardiologist evolves, together with necessary operator expertise, more complex coronary anatomy is being treated percutaneously. Abrupt vessel closure in the catheterisation laboratory is often successfully resolved by stent deployment, together with parenterally administered platelet inhibitors. Therefore, the demand for emergent surgical rescue for this sc...

Fatal complication, rescue therapy; covered stent for coronary artery perforation

“…As a result of that, their success rates are low in distal, tortuous and calcify lesions. Moreover, it was reported that with these stents, sub acute stent thrombosis and restenosis were more frequent in comparison with other stents [8].…”

“…The interventions performed for type B and C lesions defined in AHA/ACC, and athero ablation procedures that are increasingly practiced have increased the frequency of the occurrence of perforation [6,7]. Its acute onset and rapid progression to collapse and tamponade make interventions difficult [8,9]. It has been demonstrated that the type of the guide wire used, the balloon/vascular diameter ratio and oversize stent are the factors for the de-velopment of perforation [3,10].…”

Cardiogenic Shock Caused by a Large Sub-Epicardial Hematoma Complicating Percutaneous Coronary Intervention

“…This complication is seen more frequently in the treatment of chronic total occlusion [1]. However, cardiac tamponade following coronary perforation has a poor prognosis [2].…”

“…With an incidence of less than 0.5%, coronary perforation is not a frequently occurring complication of percutaneous coronary intervention (PCI) [1]. This complication is seen more frequently in the treatment of chronic total occlusion [1].…”

“Cavity spilling” perforation during recanalisation of the right coronary artery – reocclusion of the recanalised artery as a method of emergency treatment

“…Its frequency ranges from 0.1% to 3.0% [1][2][3][4]. Clinical factors predisposing to perforation include older age and female sex [1].…”