A revised algorithm for coronary perforation

Use of stent grafts and coils in vessel rupture and perforation

Vessel rupture and perforation are important complications of percutaneous treatment of coronary and peripheral arterial disease. These complications can result in abrupt vessel closure, distal organ injury, bleeding into the surrounding tissue, and death. Prompt management of such complications is therefore critically important. This paper reviews the management of vessel rupture and perforation, including the use of different types of covered stents (balloon-expandable and self-expanding), as well as the various types of embolization coils. Particular focus will be placed on percutaneous coronary artery and peripheral arterial interventions.

Acute and long-term outcome after coronary artery perforation during percutaneous coronary interventions

BACKGROUND

Coronary artery perforation is a rare but serious complication of percutaneous coronary interventions (PCI).

METHODS

We reviewed our database for cases of overt coronary perforation during PCI procedures. Hospital charts, procedural reports, and coronary angiograms of these patients were reviewed, with particular emphasis on mechanisms of perforation, management of the complication, and clinical outcome.

RESULTS

Between 01/1998 and 12/2003, a total of 19 cases (mean age: 66+/-8 years, 13 male) of coronary perforation occurred during 6433 PCI procedures performed within this period (incidence: 0.3%). In 12/19 (63%) cases, perforation occurred during recanalisation procedures of chronic total occlusions of coronary arteries. In all but one patient, non-surgical management was attempted: 2 out of 19 (11%) patients were treated conservatively by reversal of heparin anticoagulation. Prolonged balloon inflation at the perforation site was applied in 10/19 (53%) patients. Six (32%) patients received stents (5 of them received covered stentgrafts), 3 (16%) patients developed cardiac tamponade requiring percardiocentesis, and only 2 (11%) patients underwent bailout surgical repair. There were 2 (11%) deaths early after the procedure.

CONCLUSION

Coronary perforation during PCI is a rare complication, but is associated with significant morbidity and mortality. In the majority of patients, non-surgical management is both feasible and associated with a high success-rate.