Transluminal coronary angioplasty complicated by coronary artery perforation

Emergency repair of coronary perforation following percutaneous transluminal coronary angioplasty failure: A high-risk choice?

Coronary perforation is a recognized hazard following cardiac catheterization and may lead to a catastrophic outcome. Prompt decision-making following diagnosis is of key importance. Whether to perform prolonged attempts at percutaneous repair or to promptly refer the patient for emergency surgery soon after diagnosis still remains a matter of debate. We report the case of a 78-year-old woman suffering from coronary artery perforation during left anterior descending coronary artery percutaneous transluminal coronary angioplasty-stenting, who underwent unsuccessful multiple prolonged attempts at percutaneous repair followed by subsequent successful emergency surgery.

Successful management of osteal perforation of left anterior descending artery with coated stent

Coronary perforation is a rare complication of percutaneous coronary intervention. We report a case of left anterior descending artery osteal perforation that led to acute cardiac tamponade during excimer laser angioplasty. Perforation was successfully covered with a PTFE-coated stent with preserved distal coronary flow.

Coronary artery perforation during percutaneous intervention: incidence and outcome

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 risk-free 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.

Early and late clinical outcomes following coronary perforation in patients undergoing percutaneous coronary intervention

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 ajet 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 (35% and 0%, respectively), reversal of anticoagulation (57% and 94%), pericardiocentesis and drainage (27% and 61%), and prolonged perfusion balloon angioplasty (16% and 100%). Two patients with type II perforations required emergency coronary artery bypass surgery. There were no in-hospital deaths. Late pseudoaneurysms developed in 18 (28.6%) patients during the 13.4 +/- 11.3 months' follow-up period, and were more common in patients with type II perforations (72.2% vs 11.1% with type I perforations; p<0.001). During the follow-up period, no patient had evidence of coronary rupture. The results suggest that coronary perforation is uncommon after PCI, and can be managed without cardiac surgery in the majority of cases. Late pseudoaneurysms developed in some patients, particularly in patients with type II perforations, but there were no late consequences of coronary perforation after PCI.

Coronary perforation during percutaneous coronary intervention in the era of abciximab platelet glycoprotein IIb/IIIa blockade: an algorithm for percutaneous management

Coronary perforation is an uncommon but potentially life-threatening complication of percutaneous coronary intervention. The use of both atheroablative technologies for coronary intervention and adjunctive platelet glycoprotein blockade pharmacology may increase the incidence of or risk for life-threatening bleeding complications following the occurrence of coronary artery perforation. The interventional database for 6,214 percutaneous coronary interventions performed between January 1995 and June 1999 was analyzed. Hospital charts and cine angiograms for all patients identified in the database as having had coronary perforation were reviewed. Coronary perforation complicated 0.58% of all procedures and was more commonly observed in patients with a history of congestive heart failure and following use of atheroablative interventional technologies (2.8%). There was no association of abciximab therapy with either the incidence of or classification for coronary perforation. Adverse clinical outcomes (death, emergency surgical exploration) were related to the angiographic classification of perforation and were more frequently observed in patients who experienced a class 3 coronary perforation. These data suggest that specific clinical and procedural demographic factors are associated with the occurrence and severity of angiographic coronary perforation. An angiographic perforation class-specific algorithm for treatment of coronary perforation is proposed.

Incidence, management, and outcome of coronary artery perforation during percutaneous coronary intervention

We have analyzed the incidence, management, and outcome of 84 cases of coronary artery perforation in patients who underwent percutaneous coronary intervention at our institution. This complication was more frequent in female patients and in patients who underwent lesion modification with atheroablative devices. A total of 8 patients (9.5%) died after the procedure. They were usually older and had a higher incidence of cardiac tamponade; a larger percentage of these patients underwent emergency surgery than those who survived.

Cardiac tamponade in the "new device" era: evaluation of 6999 consecutive percutaneous coronary interventions

BACKGROUND

The incidence of cardiac perforation and pericardial tamponade appears to be increasing in the era of new coronary interventional devices compared with coronary balloon angioplasty.

METHODS AND RESULTS

We reviewed 6999 consecutive percutaneous coronary interventions performed during 1994 to 1996 in a single urban university hospital catheterization laboratory. Data had been collected prospectively as part of an ongoing quality assurance program. Fifteen patients had cardiac tamponade within 36 hours of the procedure. Only 6 of these occurred during the interventional procedure; the others occurred 2 to 36 hours later. The median patient age was 72 years. Nine (60%) patients were female. Three patients received abciximab. Five perforations were at the target coronary artery site, 3 were caused by a guide wire tip in the distal part of the target artery, and 7 represented right ventricular perforations caused by a temporary pacemaker wire. Five of the 7 right ventricular perforations occurred during rotational atherectomy procedures. Diagnosis was aided by immediate echocardiography. Treatment was medical, including pericardiocentesis, in 6 cases. The other 9 patients required surgical drainage and repair. All patients survived the index hospitalization. At 18-month follow-up, 1 patient had died, and all others were without apparent sequelae.

CONCLUSIONS

Tamponade after percutaneous coronary intervention is not rare in the "new device" era (overall incidence 0.2%); tamponade after percutaneous coronary intervention is often delayed and may occur outside the catheterization suite; patients are more likely to be female and elderly; immediate echocardiography is an essential aid to diagnosis and prompt treatment; and the use of temporary right ventricular pacing catheters must be reexamined.

Gelfoam embolization of a distal coronary artery guidewire perforation

A guidewire-induced distal coronary artery perforation presenting with cardiac tamponade was occluded by distal Gelfoam embolization via an infusion catheter. This extends the treatment options for this rare complication of coronary interventional procedures. Cathet. Cardiovasc. Intervent. 49:214-217, 2000.

Successful treatment of a saphenous vein graft perforation with an autologous vein-covered stent

A 52-year-old man with a history of prior coronary bypass surgery suffered recurrent angina and underwent percutaneous placement of a stent within the midportion of the saphenous vein graft to the marginal branch of the left circumflex coronary artery, which was complicated by a significant perforation. The perforation was successfully closed using an NIR stent covered with a segment of autologous antecubital vein. Subsequent surgical exploration confirmed successful closure of the perforation. Cathet. Cardiovasc. Intervent. 48:382-386, 1999.

Occurrence of a saccular pseudoaneurysm formation two weeks after perforation of the left anterior descending coronary artery during balloon angioplasty in acute myocardial infarction

We describe the occurrence of a localized saccular pseudoaneurysm in a 69-year-old patient 2 weeks after perforation of the left anterior descending coronary artery during balloon angioplasty in acute myocardial infarction. The therapy of perforations requires prolonged balloon inflations, perfusion balloons, covered stents, or surgery. Coronary peudoaneurysm formations are rare; their therapy requires covered stents or surgery. Cathet. Cardiovasc. Intervent. 47:341-346, 1999.

Complete left atrial obliteration due to localized tamponade after coronary artery perforation during PTCA

Coronary artery perforation is a rare but important complication of percutaneous revascularization (PTCA). Clinical events following coronary perforation may include cardiac tamponade. After bypass graft operation (CABG), however, cardiac tamponade with subsequent hemodynamic instability is unusual due to the development of pericardial adhesions. We report an unusual case of localized tamponade after coronary artery perforation during PTCA in a patient with previous CABG.

Percutaneous bailout therapy of a perforated vein graft using a stent-autologous vein patch

A 74-yr-old man with two prior coronary bypass surgeries experienced perforation of an occluded aortocoronary vein graft during a transluminal extraction catheter (TEC) procedure for unstable angina. The perforation was successfully closed using a Palmaz 154 stent covered with a short segment of autologous antecubital vein.

Successful closure of a coronary vessel rupture with a vein graft stent: case report

We report a successfully percutaneous closure of a brisk coronary artery rupture with a custom-made "vein graft stent," a Palmaz-Schatz stent covered with a vein graft. This method is an elegant and effective alternative to the traditional surgical approach and should be considered whenever technically and clinically feasible.

Repair of a coronary pseudoaneurysm with percutaneous placement of a saphenous vein allograft attached to a biliary stent

Late coronary artery pseudoaneurysm formation is a rare complication of perforation following percutaneous intervention. While surgical intervention is the treatment of choice for large expanding pseudoaneurysms, the optimal treatment strategy for small-to-moderate pseudoaneurysms is unclear. We describe the percutaneous placement of a saphenous vein allograft for treatment of a coronary artery pseudoaneurysm presenting as a late complication of coronary perforation.

Perforation of a side branch of the right coronary artery during selective coronary angiography using 5 French Judkins catheters

In this case report the first known case of a perforation of a side branch of the right coronary artery during diagnostic coronary angiography using 5 French Judkins catheters is described which occurred by selective intubation. Although catheter placement was controlled by contrast test injection the catheter occasionally intubated the conus artery super selectively just prior to the diagnostic injection. Thus, perforation of small side branches may be encountered especially by the use of 5 French Judkins catheters.

Management of coronary artery rupture: covered stent or microcoil embolization

The management of three cases of coronary artery rupture is described: (1) after high-pressure balloon angioplasty following uneventful placement of three Gianturco-Roubin stents, (2) following balloon angioplasty of an occluded diagonal branch, and (3) subsequent to rotational ablation of a left main and proximal circumflex arteries. Placement of an autologous vein-covered Palmaz stent or microcoil embolic vessel occlusion solved each problem. In each case, emergency surgery was avoided; subsequent management, including anticoagulation (when indicated), was performed without incident. This is the first communication detailing correction of a coronary vessel rupture with an autologous vein-covered stent or by microcoil embolic vessel occlusion.

Increased coronary perforation in the new device era. Incidence, classification, management, and outcome

BACKGROUND

The incidence of coronary perforation using new percutaneous revascularization techniques may be increased compared with PTCA. Still, perforation is uncommonly reported, and the optimal management and expected outcome remain unknown. The objectives of the study were to determine the incidence of coronary perforation using balloon angioplasty (percutaneous transluminal coronary angioplasty, PTCA) and new revascularization techniques and to develop optimal strategies for its management based on classification and outcome.

METHODS AND RESULTS

Eleven sites with frequent use of new revascularization devices and prospective coding of consecutive procedures for coronary perforation during 1990 to 1991 contributed to a perforation registry. Patients with perforation were matched by device with an equal-sized cohort without perforation. Data were collected centrally, and all procedural cineangiograms were reviewed at a core angiographic laboratory. A classification scheme based on angiographic appearance of the perforation (I, extraluminal crater without extravasation; II, pericardial or myocardial blushing; III, perforation > or = 1-mm diameter with contrast streaming; and cavity spilling) was evaluated as a predictor of outcome and as a basis for management. Perforation was observed in 62 of 12,900 procedures reported (0.5%; 95% confidence interval, 0.4% to 0.6%), more commonly with devices intended to remove or ablate tissue (atherectomy, laser) than with PTCA (1.3%, 0.9% to 1.6% versus 0.1%, 0.1% to 0.1%; P < .001). The perforation population was notable for its advanced age (67 +/- 10 years) and high incidence of female sex (46%) (both P < .001 compared with patients without perforation). Perforation could be treated expectantly or with PTCA but without cardiac surgery in 85%, 90%, and 44% of class I, II, and III perforations, respectively. Class I perforations (n = 13, 21%) were associated with death in none, myocardial infarction in none, and tamponade in 8%. The incidences of these adverse events were 0%, 14%, and 13% in class II perforations (n = 31, 50%) and 19%, 50%, and 63% in non-cavity spilling class III perforations, respectively (n = 16, 26%). Two of the 15 instances of cardiac tamponade (13%) were delayed, occurring within 24 hours after dismissal from the catheterization laboratory.

CONCLUSION

The incidence of perforation, while low, is increased with new devices. Women and the elderly are at highest risk. The clinical risk after perforation can be classified angiographically, but even low-risk perforations occasionally have poor clinical outcome. Patients should be observed for delayed cardiac tamponade for at least 24 hours.

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

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%).

Coronary perforation after excimer laser coronary angioplasty: the Excimer Laser Coronary Angioplasty Registry experience

OBJECTIVES

This study assessed the frequency of perforation with excimer coronary angioplasty.

BACKGROUND

Coronary artery perforation after conventional percutaneous transluminal coronary angioplasty is extremely rare. Because laser coronary angioplasty involves actual tissue ablation, it has an increased potential for perforation.

METHODS

All patients in the Excimer Laser Coronary Angioplasty Registry were included in this prospective study. Those who had a perforation related to the procedure were compared with those who did not have this complication.

RESULTS

Of 2,759 consecutive patients in the Excimer Laser Coronary Angioplasty Registry, 36 (1.3%) had perforation. In these patients, the left anterior descending coronary artery was the most frequently treated vessel (53%). There were no differences in fiber sizes between patients with and those without perforation. Among the patients with perforation, 36.1% required coronary artery bypass surgery, 16.7% experienced an infarction and 5.6% had a fatal outcome. Among the patients without perforation, the rates were 3.1%, 3.8% and 0.6%, respectively. However, 41.7% of the patients with documented coronary artery perforation did not need coronary artery bypass surgery or experience myocardial infarction or death. No angiographic characteristics distinguished lesions with from those without perforation. The frequency of coronary artery perforation declined over time with increasing operator experience, from 1.6% in the first 1,888 patients to only 0.4% in the last 1,000 patients (p = 0.002).

CONCLUSIONS

With increasing operator experience, the rate of perforation with excimer laser coronary angioplasty has decreased. When perforation occurs, subsequent event rates increase.

Coronary artery rupture during transluminal coronary recanalization and angioplasty in a case of acute myocardial infarction and shock

Percutaneous transluminal coronary angioplasty (PTCA) is a widely performed and effective therapy for coronary artery disease. Evolution of the dilatation instruments during the last decade has led to an increased success rate of PTCA and to the development of newer techniques such as recanalization of totally occluded coronary arteries. We report a case of coronary artery recanalization complicated by fatal coronary artery rupture.

Coronary artery perforation during excimer laser coronary angioplasty. The percutaneous Excimer Laser Coronary Angioplasty Registry

OBJECTIVES

The aim of this study was to analyze the risk of vessel perforation during excimer laser angioplasty.

BACKGROUND

Vessel perforation is a serious complication of angioplasty.

METHODS

A total of 764 patients had 858 stenoses treated with excimer laser angioplasty. Laser catheters had a diameter of 1.4, 1.7 or 2 mm. Laser energy was delivered in pulses of 135 ns, at a frequency of 25 s-1 and at a fluence of 30 to 60 mJ/mm2. Follow-up angiography was requested for all patients who did not require emergency bypass surgery.

RESULTS

In the 764 consecutive patients treated with excimer laser coronary angioplasty, vessel perforation occurred in 23 patients (3%). Nine patients had a major complication resulting directly from vessel perforation (cardiac tamponade, myocardial infarction or need for bypass surgery) and 14 had no clinical complications after successful sealing of the puncture site. No patient with a perforation died. Multivariate analysis showed that bifurcation lesions (odds ratio [OR] = 3.5; p = 0.049), diabetes mellitus (OR = 3.15; p = 0.029) and female gender (OR = 2.86; p = 0.013) were associated with an increased risk of vessel perforation. Lesions > 10 mm in length (OR = 0.45; p = 0.206), calcified stenoses (OR = 0.26; p = 0.088) and saphenous vein graft lesions (OR = 0.50; p = 0.295) were not at increased risk. Vessel perforation was seen in 10 (8.3%) of 120 lesions in which the laser catheter was equivalent in diameter to the target vessel (< or = 0.5 mm smaller in size) but in only 8 (1.5%) of 525 lesions in which the laser catheter was > 1 mm smaller than the target vessel (p = 0.001).

CONCLUSIONS

Most lesions thought to be suitable for excimer laser treatment are not at increased risk of perforation. The complication may be avoided by improved patient and laser catheter size selection.

Coronary artery rupture and pseudoaneurysm formation resulting from percutaneous coronary angioscopy

We describe a case in which coronary angioscopy was complicated by inability to deflate the device's occlusion balloon. Rapid over-inflation to rupture the balloon resulted in massive dissection of the artery, pseudoaneurysm formation, and ultimately coronary bypass. While the cause of failure of balloon deflation remains obscure, deliberate over-inflation to cause rupture may be hazardous.

Cardiac tamponade following coronary arterial rupture during coronary angioplasty

We describe a patient in whom percutaneous transluminal coronary angioplasty (PTCA) was complicated by rupture of the left anterior descending coronary artery (LAD) with pericardial tamponade. The outcome was favorable with drastic intervention which included: occlusion of the bleeding vessel with the PTCA balloon, pericardiocentesis, and ligation of the vessel without the need of aortocoronary bypass graft.

Successful treatment of an excimer laser-associated coronary artery perforation with the Stack perfusion catheter

A 64-year-old woman underwent excimer laser angioplasty of the right coronary artery. The procedure was complicated by perforation, which was successfully managed without complication with a Stack perfusion catheter. This report describes successful nonsurgical treatment of laser-induced coronary perforation and makes recommendations for avoiding this complication in other patients.

Pinhole balloon rupture during coronary angioplasty causing rupture of the coronary artery

We report a case of pinhole balloon rupture during percutaneous transluminal coronary angioplasty using one of the newer catheters. Pinhole balloon rupture resulted in rupture and occlusion of the vessel being dilated.

Saphenous vein graft rupture during percutaneous transluminal angioplasty

Three cases (one fatal) of a rare angioplasty complication, vein graft rupture, are presented with a review of the literature. Caution is suggested when oversizing balloons for vein graft dilatation.

Entrapment of an angioplasty balloon catheter: a case report

This report presents a case in which an angioplasty balloon catheter became entrapped within the lumen of a coronary artery after rupture during percutaneous transluminal coronary angioplasty (PTCA). Prior to this report, balloon rupture had been considered a relatively benign occurrence. However, this case demonstrates that balloon rupture may lead to serious complications.

Rupture of a saphenous vein bypass graft during coronary angioplasty

A self-limited rupture of a five month old saphenous vein bypass graft occurred during coronary angioplasty when the balloon used to stretch the vessel proved to be too large. A lack of fibrous tissue in the new graft may have predisposed it to rupture.

Immediate balloon inflation during ventricular fibrillation complicating coronary angioplasty--an alternative technique to angioplasty system withdrawal: case reports and review

Two patients are presented in whom ventricular fibrillation occurred during otherwise uncomplicated percutaneous transluminal coronary angioplasty. Rather than withdrawing the angioplasty dilatation system in place in the coronary vessel before instituting resuscitation procedures, immediate balloon inflation was performed while a defibrillator was charged. During balloon inflation, both patients were countershocked, and they recovered stable cardiac rhythm. Postresuscitation hemodynamic and angiographic analysis revealed successful angioplasty results. This report describes an alternative technique to immediate removal of the balloon dilatation system for cardiac arrest complicating coronary angioplasty. Theoretical advantages and potential disadvantages of this technique are discussed.

Coronary artery perforation during coronary angioplasty

In one patient percutaneous transluminal coronary angioplasty was complicated by coronary artery perforation of the left anterior descending coronary artery with light pericardial effusion. The outcome was favorable without either pericardiocentesis or emergency surgery.

New balloon catheter for prolonged percutaneous transluminal coronary angioplasty and bypass flow in occluded vessels

A new balloon catheter was developed for continuous perfusion of coronary arteries during angioplasty (CPC catheter). Steerable Grüntzig balloon catheters (3.7 mm) with two lumina were formed. The first lumen was used for balloon inflation. Side holes to the second lumen proximally and distally to the balloon were created for coronary perfusion even during inflation phase. At a perfusion pressure of 120 mmHg, a flow rate of 63 +/- 3 ml/min with 0.9% saline and 43 +/- 1 ml/min with plasma expander were measured. In experiments on five dogs, dilation time until appearance of signs of ischemia could be prolonged in three of five dogs from 30 to 40 s, 120 to 203 s, and 180 to 420 s comparing conventional and CPC balloon catheters. In 11 patients with proximal lesions, dilation time could be increased from 39.5 +/- 23.9 s to 81.1 +/- 36.3 s (p less than 0.01) until appearance of angina pectoris. ST segment changes were observed in 10/11 patients using conventional catheters. Using CPC catheters, no ST segment changes were observed in four patients; time until appearance of ST segment changes was delayed in the other seven patients. The CPC catheter seems to be an alternative catheter in proximal lesions of the left and right coronary artery, allowing the possibility of prolonged dilation and increased safety to the patient. In case of dissection or perforation, the CPC catheter can be used for perfusion of the distal part of the coronary vessel until emergency bypass surgery.

Benign coronary perforation during percutaneous transluminal coronary angioplasty

In two patients percutaneous transluminal coronary angioplasty was complicated by coronary perforation. In both cases the complication was managed conservatively.

Cardiac tamponade following percutaneous transluminal coronary angioplasty: four case reports

Percutaneous transluminal coronary angioplasty (PTCA) has had complications related to dilating catheters and guide wires such as coronary artery dissection, spasm, rupture, and perforation. This report describes four patients who developed cardiac tamponade following PTCA, presumably from right ventricular (RV) perforation. All four received large doses of heparin during PTCA and three received antiplatelet therapy. In three cases, cardiac tamponade occurred several hours after PTCA. All patients did well following operative intervention and no patient required repair of a cardiac perforation. We postulate that impaired hemostasis in the presence of an otherwise inconsequential RV perforation causes tamponade. Three alternatives to provide standby pacing are proposed.

Transverse aortic wall tears in infants after balloon angioplasty for aortic valve stenosis: relation of aortic wall damage to diameter of inflated angioplasty balloon and aortic lumen in seven necropsy cases

Aortic wall tears resulting from rupture of dilating balloons in infants undergoing transluminal balloon angioplasty have not been previously recognized. A 2 day old infant had percutaneous transluminal balloon angioplasty to dilate a stenotic aortic valve, and after multiple balloon inflations the balloon burst. The infant died 2 days after undergoing transluminal balloon angioplasty and at necropsy a circumferential, transverse aortic wall tear was found. To test the hypothesis that rupture of appropriately sized balloons results in similar aortic wall tears, six unfixed, intact infant aortas were subjected to transluminal balloon angioplasty at necropsy: two infants had balloon rupture with inflated balloon diameter similar to that of the aorta, two had balloon rupture with an undersized balloon and two had dilation with an oversized balloon. Transverse wall tears occurred in aortas with similar aortic and balloon diameters; no aortic wall damage occurred with rupture of undersized balloons, and aortic rupture resulted from the use of oversized balloons. Thus, intimal-medial tears in the infant aorta may result from balloon bursting during angioplasty when aortic and inflated balloon diameters are similar.