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Mikhail P, Howden N, Monjur M, Jeyaprakash P, Said C, Bland A, Collison D, McCartney P, Adamson C, Morrow A, Carrick D, McEntegart M, Ford TJ. Coronary perforation incidence, outcomes and temporal trends (COPIT): a systematic review and meta-analysis. Open Heart 2022; 9:openhrt-2022-002076. [PMID: 36270713 PMCID: PMC9594565 DOI: 10.1136/openhrt-2022-002076] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 09/06/2022] [Indexed: 11/13/2022] Open
Abstract
Coronary perforation is a potentially life-threatening complication of percutaneous coronary intervention (PCI). We studied incidence, outcomes and temporal trends following PCI-related coronary artery perforation (CAP). METHODS Prospective systematic review and meta-analysis including meta-regression using MEDLINE and EMBASE to November 2020. We included 'all-comer' PCI cohorts including large PCI registries and randomised controlled trials and excluding registries or trials limited to PCI in high-risk populations such as chronic total occlusion PCI or cohorts treated only with atheroablative devices. Regression analysis and corresponding correlation coefficients were performed comparing perforation incidence, mortality rate, tamponade rate and the rate of Ellis III perforations against the midpoint (year) of data collection to determine if a significant temporal relationship was present. RESULTS 3997 studies were screened for inclusion. 67 studies met eligibility criteria with a total of 5 568 191 PCIs included over a 38-year period (1982-2020). The overall pooled incidence of perforation was 0.39% (95% CI 0.34% to 0.45%) and remained similar throughout the study period. Around 1 in 5 coronary perforations led to tamponade (21.1%). Ellis III perforations are increasing in frequency and account for 43% of all perforations. Perforation mortality has trended lower over the years (7.5%; 95% CI 6.7% to 8.4%). Perforation risk factors derived using meta-regression were female sex, hypertension, chronic kidney disease and previous coronary bypass grafting. Coronary perforation was most frequently caused by distal wire exit (37%) followed by balloon dilation catheters (28%). Covered stents were used to treat 25% of perforations, with emergency cardiac surgery needed in 17%. CONCLUSION Coronary perforation complicates approximately 1 in 250 PCIs. Ellis III perforations are increasing in incidence although it is unclear whether this is due to reporting bias. Despite this, the overall perforation mortality rate (7.5%) has trended lower in recent years. Limitations of our findings include bias that may be introduced through analysis of multidesign studies and registries without pre-specified standardised perforation reporting CMore research into coronary perforation management including the optimal use of covered stents seems warranted. PROSPERO REGISTRATION NUMBER CRD42020207881.
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Affiliation(s)
- Philopatir Mikhail
- Department of Cardiology, Central Coast Local Health District, Gosford, New South Wales, Australia,Faculty of Medicine, The University of Newcastle, Newcastle, NSW, Australia
| | - Nicklas Howden
- Department of Cardiology, Central Coast Local Health District, Gosford, New South Wales, Australia,Faculty of Medicine, The University of Newcastle, Newcastle, NSW, Australia
| | - Mohammad Monjur
- Department of Cardiology, South Eastern Sydney Local Health District, Kogarah, New South Wales, Australia
| | - Prajith Jeyaprakash
- Department of Cardiology, Nepean Hospital, Penrith, New South Wales, Australia
| | - Christian Said
- Department of Cardiology, Central Coast Local Health District, Gosford, New South Wales, Australia
| | - Adam Bland
- Department of Cardiology, Central Coast Local Health District, Gosford, New South Wales, Australia,Faculty of Medicine, The University of Newcastle, Newcastle, NSW, Australia
| | - Damien Collison
- Department of Cardiology, Golden Jubilee Hospital, Clydebank, UK,Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Peter McCartney
- Department of Cardiology, Golden Jubilee Hospital, Clydebank, UK,Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Carly Adamson
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Andrew Morrow
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - David Carrick
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK,Department of Cardiology, University Hospital Hairmyres, East Kilbride, UK
| | | | - Thomas J Ford
- Department of Cardiology, Central Coast Local Health District, Gosford, New South Wales, Australia,Faculty of Medicine, The University of Newcastle, Newcastle, NSW, Australia,Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
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2
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Gawalkar AA, Singh N, Gupta A, Barwad P. Looped wire advancement—not always safe! Fat—not so useless! a case series. Eur Heart J Case Rep 2021; 5:ytab400. [PMID: 34816082 PMCID: PMC8603226 DOI: 10.1093/ehjcr/ytab400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 06/03/2021] [Accepted: 10/04/2021] [Indexed: 11/12/2022]
Abstract
Background Coronary artery perforation (CAP), although rare, can often be a life-threatening complication of percutaneous coronary intervention. Looped wire tip or buckling of wire is conventionally considered safer due to reduced risk of migration into smaller branches and false lumen. Occasionally, buckling can indicate the entry of tip into dissection plane, or the advancement of looped wire can cause small vessel injury leading to perforation. Distal coronary perforation can be life threatening and coil, foam, and thrombin injection are some of the material widely used for sealing it. Case summary We hereby report three different cases illustrating the vessel injury that the looped wire can cause in the distal vasculature related to various mechanisms like high elastic recoil tension, dissection by the non-leading wire tip, or hard wire lacerating the fragile small branches. All these mechanisms lead to distal coronary perforation leading to cardiac tamponade. Each case also illustrate the novel technique of autologous fat globule embolization for the management of distal CAP. Discussion Distal coronary perforation is often due to guidewire-related vessel injury and is more common with hydrophilic wires. Looped wire tip can sometime indicate vessel injury and its advancement further down the coronary artery may result in serious vessel injury and perforation. Management of distal coronary perforation is challenging, and here we demonstrate the steps of using the readily available autologous fat globules by selectively injecting them into the small coronary artery to control the leak.
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Affiliation(s)
- Atit A Gawalkar
- Department of Cardiology, Post Graduate Institute of Medical Education & Research , Sector 12 , Chandigarh 160 012, India
| | - Navreet Singh
- Department of Cardiology, Air Force Central Medical Establishment, Subroto Park, New Delhi, 110010 , India
| | - Ankush Gupta
- Department of Cardiology, Military Hospital, Bani Park, Jaipur, Rajasthan, 302016 , India
| | - Parag Barwad
- Department of Cardiology, Post Graduate Institute of Medical Education & Research , Sector 12 , Chandigarh 160 012, India
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3
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Voskoboinik A, Butcher E, Sandhu A, Nguyen DT, Tzou W, Della Rocca DG, Natale A, Zado ES, Marchlinski FE, Aguilar M, Sauer W, Tedrow UB, Gerstenfeld EP. Direct Thrombin Inhibitors as an Alternative to Heparin During Catheter Ablation: A Multicenter Experience. JACC Clin Electrophysiol 2020; 6:484-490. [PMID: 32276868 DOI: 10.1016/j.jacep.2019.12.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 11/22/2019] [Accepted: 12/03/2019] [Indexed: 10/24/2022]
Abstract
OBJECTIVES The goal of this study was to report a multicenter series of left-sided catheter ablations performed by using intravenous direct thrombin inhibitors (DTIs) as an alternative to heparin. BACKGROUND Amidst a looming worldwide shortage of heparin, there are insufficient data to guide nonheparin-based peri-procedural anticoagulation in patients undergoing catheter ablation. METHODS This study reviewed all catheter ablations at 6 institutions between 2006 and 2019 to assess the safety and efficacy of DTIs for left-sided radiofrequency catheter ablation of atrial fibrillation and ventricular tachycardia. RESULTS In total, 53 patients (age 63.0 ± 9.3 years, 68% male, CHA₂DS₂-VASc [congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, stroke/transient ischemic attack, vascular disease, age 65 to 74 years, sex category] score 2.8 ± 1.6, left ventricular ejection fraction 46 ± 15%) underwent ablation with DTIs (75% bivalirudin, 25% argatroban) due to heparin contraindication(s) (72% heparin-induced thrombocytopenia, 21% heparin allergy, 4% protamine reaction, and 4% religious reasons). The patient's usual oral anticoagulant was continued without interruption in 69%. Procedures were performed for atrial fibrillation (64%) or ventricular tachycardia/premature ventricular contractions (36%). Transseptal puncture was undertaken in 81%, and a contact force-sensing catheter was used in 70%. Vascular ultrasound was used in 71%, and femoral arterial access was gained in 36%. A bolus followed by infusion was used in all but 4 cases, and activated clotting time was monitored peri-procedurally in 72%, with 32% receiving additional boluses. Procedure duration was 216 ± 116 min, and ablation time was 51 ± 22 min. No major bleeding or embolic complications were observed. Four patients had minor self-limiting bleeding complications, including a small pericardial effusion (<1 cm), a small groin hematoma, and hematuria. CONCLUSIONS In this multicenter series, intravenous DTIs were safely used as an alternative to heparin for left-sided catheter ablation.
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Affiliation(s)
- Aleksandr Voskoboinik
- Division of Cardiology, University of California San Francisco, San Francisco, California, USA; Division of Cardiology, Alfred Hospital and Baker Heart Institute, Melbourne, Australia
| | - Eric Butcher
- Division of Cardiology, University of Colorado, Denver, Colorado, USA
| | - Amneet Sandhu
- Division of Cardiology, University of Colorado, Denver, Colorado, USA
| | - Duy T Nguyen
- Division of Cardiology, University of Colorado, Denver, Colorado, USA
| | - Wendy Tzou
- Division of Cardiology, University of Colorado, Denver, Colorado, USA
| | | | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA
| | - Erica S Zado
- Division of Electrophysiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Francis E Marchlinski
- Division of Electrophysiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Martin Aguilar
- Cardiac Arrhythmia Service, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - William Sauer
- Cardiac Arrhythmia Service, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Usha B Tedrow
- Cardiac Arrhythmia Service, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Edward P Gerstenfeld
- Division of Cardiology, University of California San Francisco, San Francisco, California, USA.
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4
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Shaukat A, Tajti P, Sandoval Y, Stanberry L, Garberich R, Nicholas Burke M, Gössl M, Henry T, Mooney M, Sorajja P, Traverse J, Bradley SM, Brilakis ES. Incidence, predictors, management and outcomes of coronary perforations. Catheter Cardiovasc Interv 2018; 93:48-56. [PMID: 30312992 DOI: 10.1002/ccd.27706] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 05/30/2018] [Indexed: 11/10/2022]
Abstract
OBJECTIVES We examined the contemporary incidence, types, predictors, angiographic characteristics, management and outcomes of coronary perforation. BACKGROUND Coronary perforation is a rare, but important, complication of percutaneous coronary intervention (PCI). There is lack of data on perforations stratified as large and distal vessel perforations. METHODS Retrospective, observational cohort study of all patients who underwent PCI at a high volume, tertiary hospital between the years 2009 and 2016. Angiograms of all coronary perforation cases were reviewed to determine the mechanism, type, and management of perforation. Risk-adjusted periprocedural complication rates were compared between patients with and without coronary perforation. One-year mortality outcomes of patients with large vessel vs. distal vessel perforation were also examined. RESULTS Coronary perforation occurred in 68 of 13,339 PCIs (0.51%) performed during the study period: 51 (75%) were large vessel perforations and 17 (25%) distal vessel perforations. Most (67%) large vessel perforations were due to balloon/stent inflation, whereas most (94%) distal vessel perforations were due to guidewire exit. Patients with coronary perforations had significantly higher risk for periprocedural complications (adjusted odds ratio 7.57; 95% CI: 4.22-13.50; P < 0.001). Only one patient with large vessel perforation required emergency cardiac surgery, yet in-hospital mortality was high with both large vessel (7.8%) and distal vessel (11.8%) perforations. CONCLUSIONS Coronary perforation is an infrequent, but potentially severe PCI complication. Most coronary perforations are large vessel perforations. Although coronary perforations rarely lead to emergency cardiac surgery, both distal vessel and large vessel perforations are associated with high in-hospital mortality, highlighting the importance of prevention.
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Affiliation(s)
- Arslan Shaukat
- Minneapolis Heart Institute, Abbott Northwestern Hospital and Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
| | - Peter Tajti
- Minneapolis Heart Institute, Abbott Northwestern Hospital and Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
| | - Yader Sandoval
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Larissa Stanberry
- Minneapolis Heart Institute, Abbott Northwestern Hospital and Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
| | - Ross Garberich
- Minneapolis Heart Institute, Abbott Northwestern Hospital and Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
| | - M Nicholas Burke
- Minneapolis Heart Institute, Abbott Northwestern Hospital and Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
| | - Mario Gössl
- Minneapolis Heart Institute, Abbott Northwestern Hospital and Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
| | - Timothy Henry
- Minneapolis Heart Institute, Abbott Northwestern Hospital and Minneapolis Heart Institute Foundation, Minneapolis, Minnesota.,Cedars Sinai Medical Center, Los Angeles, California
| | - Michael Mooney
- Minneapolis Heart Institute, Abbott Northwestern Hospital and Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
| | - Paul Sorajja
- Minneapolis Heart Institute, Abbott Northwestern Hospital and Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
| | - Jay Traverse
- Minneapolis Heart Institute, Abbott Northwestern Hospital and Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
| | - Steven M Bradley
- Minneapolis Heart Institute, Abbott Northwestern Hospital and Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
| | - Emmanouil S Brilakis
- Minneapolis Heart Institute, Abbott Northwestern Hospital and Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
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5
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6
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Li C, Xu R, Shen Y, Dai Y, Zhang F, Ma J, Ge L, Qian J, Ge J. Bivalirudin in percutaneous coronary intervention for chronic total occlusion: A single-center pilot study. Catheter Cardiovasc Interv 2017; 91:679-685. [PMID: 28766879 DOI: 10.1002/ccd.27181] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2016] [Revised: 05/12/2017] [Accepted: 06/08/2017] [Indexed: 11/11/2022]
Affiliation(s)
- Chenguang Li
- Department of Cardiology; Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases; Shanghai 200032 China
| | - Rende Xu
- Department of Cardiology; Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases; Shanghai 200032 China
| | - Yi Shen
- Department of Geriatrics; Zhongshan Hospital, Fudan University; Shanghai 200032 China
| | - Yuxiang Dai
- Department of Cardiology; Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases; Shanghai 200032 China
| | - Feng Zhang
- Department of Cardiology; Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases; Shanghai 200032 China
| | - Jianying Ma
- Department of Cardiology; Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases; Shanghai 200032 China
| | - Lei Ge
- Department of Cardiology; Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases; Shanghai 200032 China
| | - Juying Qian
- Department of Cardiology; Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases; Shanghai 200032 China
| | - Junbo Ge
- Department of Cardiology; Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases; Shanghai 200032 China
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7
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Shemisa K, Karatasakis A, Brilakis ES. Management of guidewire-induced distal coronary perforation using autologous fat particles versus coil embolization. Catheter Cardiovasc Interv 2016; 89:253-258. [PMID: 27143506 DOI: 10.1002/ccd.26542] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Revised: 02/09/2016] [Accepted: 03/11/2016] [Indexed: 11/06/2022]
Abstract
Distal coronary perforation is a rare, yet potentially lethal complication of percutaneous coronary intervention. Early recognition and treatment remains critical in preventing potentially life-threatening adverse outcomes, such as cardiac tamponade. The most commonly used strategies for treating distal perforation are fat and coil embolization. We present two cases of guidewire-induced distal coronary perforation and discuss the advantages and disadvantages of coil vs. fat embolization. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Kamal Shemisa
- Division of Cardiovascular Diseases, VA North Texas Healthcare System and University of Texas Southwestern Medical Center, Dallas, Texas
| | - Aris Karatasakis
- Division of Cardiovascular Diseases, VA North Texas Healthcare System and University of Texas Southwestern Medical Center, Dallas, Texas
| | - Emmanouil S Brilakis
- Division of Cardiovascular Diseases, VA North Texas Healthcare System and University of Texas Southwestern Medical Center, Dallas, Texas
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8
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Cardiac tamponade arising from a venous source following anterograde dissection re-entry coronary angioplasty to a chronic total occlusion. Cardiovasc Interv Ther 2015; 31:288-91. [DOI: 10.1007/s12928-015-0351-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Accepted: 08/20/2015] [Indexed: 10/23/2022]
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9
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Chin Yong A, Wei Chieh JT. Coronary Perforation Complicating Percutaneous Coronary Intervention - A Case Illustration and Review. ACTA ACUST UNITED AC 2014; 21:3. [PMID: 26316662 PMCID: PMC4544476 DOI: 10.7603/s40602-013-0002-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Coronary perforation is a potentially fatal complication during percutaneous coronary intervention (PCI). Reports have shown that it occurs in 0.2 to 0.6% of all patients undergoing the procedures. [1-3] Though the frequency of coronary perforation is low, it is a serious and potentially life-threatening situation that warrants prompt recognition and management. Here we illustrate a case of coronary perforation, and review the incidence, causes, clinical sequelae and management of coronary perforation in the current contemporary practice.
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Affiliation(s)
- Ang Chin Yong
- Department of Cardiology, National Heart Centre Singapore, Singapore, Singapore
| | - Jack Tan Wei Chieh
- Department of Cardiology, National Heart Centre Singapore, Singapore, Singapore
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10
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Balloon Occlusion Types in the Treatment of Coronary Perforation during Percutaneous Coronary Intervention. Cardiol Res Pract 2014; 2014:784018. [PMID: 25506463 PMCID: PMC4258336 DOI: 10.1155/2014/784018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Revised: 11/07/2014] [Accepted: 11/11/2014] [Indexed: 12/31/2022] Open
Abstract
Coronary artery perforation is an uncommon complication in patients with coronary heart disease undergoing percutaneous coronary intervention. However, pericardial tamponade following coronary artery perforation may be lethal, and prompt treatment is crucial in managing such patients. Balloon occlusion and the reversal of anticoagulant activity are the common methods used to prevent cardiac tamponade by reducing the amount of bleeding. Herein, we discuss the pros and cons of currently used occlusion types for coronary perforation. Optimal balloon occlusion methods should reduce the amount of bleeding and ameliorate subsequent myocardial ischemia injury, even during cardiac surgery.
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11
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Kini A, Yu J, Cohen MG, Mehran R, Baber U, Sartori S, Vlachojannis GJ, Kovacic JC, Pyo R, O’Neill B, Singh V, Jacobs E, Poludasu S, Moreno P, Kim MC, Krishnan P, Sharma SK, Dangas GD. Effect of bivalirudin on aortic valve intervention outcomes study: a two-centre registry study comparing bivalirudin and unfractionated heparin in balloon aortic valvuloplasty. EUROINTERVENTION 2014; 10:312-9. [DOI: 10.4244/eijv10i3a54] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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12
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Maehara A, Mintz GS, Bui AB, Pichard AD, Satler LF, Waksman R, Suddath WO, Kent KM, Weissman NJ. Intravascular ultrasound evidence of perivascular trauma during routine percutaneous coronary intervention. Int J Cardiovasc Imaging 2014; 30:849-56. [DOI: 10.1007/s10554-014-0413-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Accepted: 03/28/2014] [Indexed: 12/22/2022]
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13
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Srinivas SK, Patra S, Ramalingam R, Agrawal N, Syed T, Shankarappa RK, Manjunath CN. Successful management of Ellis type III left anterior descending artery perforation following percutaneous coronary intervention by a covered stent: Successfully resolved the dramatic complication. J Cardiovasc Dis Res 2014; 4:245-7. [PMID: 24653590 DOI: 10.1016/j.jcdr.2014.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2013] [Accepted: 01/12/2014] [Indexed: 11/26/2022] Open
Abstract
Coronary artery perforation is a rare but catastrophic complication of percutaneous coronary intervention (PCI). Grade III coronary perforation and rupture invariably results in pericardial effusion and tamponade requiring urgent pericardiocentesis. Advances in coronary intervention have increased the opportunity to treat coronary artery perforation. We are reporting a case of 55 years old hypertensive female who presented with effort angina. Coronary angiogram revealed significant stenosis in the left anterior descending coronary artery. Post PCI, she had Ellis type III coronary perforation and pericardial tamponade and cardiogenic shock. The patient was resuscitated, pericardiocentesis done, autologous blood transfusion given and covered stent deployed.
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Affiliation(s)
- Sunil Kumar Srinivas
- Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences & Research, Bangalore, Karnataka 560069, India
| | - Soumya Patra
- Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences & Research, Bangalore, Karnataka 560069, India
| | - Rangaraj Ramalingam
- Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences & Research, Bangalore, Karnataka 560069, India
| | - Navin Agrawal
- Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences & Research, Bangalore, Karnataka 560069, India
| | - Tanveer Syed
- Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences & Research, Bangalore, Karnataka 560069, India
| | - Ravindranath K Shankarappa
- Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences & Research, Bangalore, Karnataka 560069, India
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Coronary artery perforation treated with multiple bare metal stent implantation. ADVANCES IN INTERVENTIONAL CARDIOLOGY 2014; 9:397-400. [PMID: 24570761 PMCID: PMC3927117 DOI: 10.5114/pwki.2013.38874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2013] [Revised: 07/17/2013] [Accepted: 08/08/2013] [Indexed: 11/17/2022] Open
Abstract
Although coronary artery perforations are quite rare, when they occur, the consequences are devastating. Treatment options differ according to the type, location and severity of the perforation. As a general rule severe perforations are treated with covered stents. However, when implanting a covered stent is not an option as in our case due to various reasons, multiple bare metal stent implantation may be a good option. Besides that, management of the antiplatelet and the anticoagulant therapy remains controversial. We believe that therapy should be individualized.
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Stathopoulos IA, Kossidas K, Garratt KN. Delayed perforation after percutaneous coronary intervention: Rare and potentially lethal. Catheter Cardiovasc Interv 2013; 83:E45-50. [DOI: 10.1002/ccd.25121] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2013] [Revised: 06/22/2013] [Accepted: 06/30/2013] [Indexed: 01/24/2023]
Affiliation(s)
- Ioannis A. Stathopoulos
- Department of Cardiac and Vascular Interventional Services New York, Lenox Hill Hospital, Heart and Vascular Institute of New York; New York
| | - Konstantinos Kossidas
- Department of Cardiac and Vascular Interventional Services New York, Lenox Hill Hospital, Heart and Vascular Institute of New York; New York
| | - Kirk N. Garratt
- Department of Cardiac and Vascular Interventional Services New York, Lenox Hill Hospital, Heart and Vascular Institute of New York; New York
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KOVACIC JASONC, SHARMA AMITB, ROY SWATHI, LI JENNIFERR, NARAYAN RAJEEV, KIM DONGBIN, SHARMA SAMINK, KINI ANNAPOORNAS. GuideLiner Mother-and-Child Guide Catheter Extension
: A Simple Adjunctive Tool in PCI for Balloon Uncrossable Chronic Total Occlusions. J Interv Cardiol 2013; 26:343-50. [DOI: 10.1111/joic.12040] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Affiliation(s)
- JASON C. KOVACIC
- Cardiac Catheterization Laboratory; Cardiovascular Institute, Mount Sinai Hospital; New York New York
| | - AMIT B. SHARMA
- Cardiac Catheterization Laboratory; Cardiovascular Institute, Mount Sinai Hospital; New York New York
| | - SWATHI ROY
- Cardiac Catheterization Laboratory; Cardiovascular Institute, Mount Sinai Hospital; New York New York
| | - JENNIFER R. LI
- Cardiac Catheterization Laboratory; Cardiovascular Institute, Mount Sinai Hospital; New York New York
| | - RAJEEV NARAYAN
- Cardiac Catheterization Laboratory; Cardiovascular Institute, Mount Sinai Hospital; New York New York
| | - DONG-BIN KIM
- Cardiac Catheterization Laboratory; Cardiovascular Institute, Mount Sinai Hospital; New York New York
| | - SAMIN K. SHARMA
- Cardiac Catheterization Laboratory; Cardiovascular Institute, Mount Sinai Hospital; New York New York
| | - ANNAPOORNA S. KINI
- Cardiac Catheterization Laboratory; Cardiovascular Institute, Mount Sinai Hospital; New York New York
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17
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Douglas CJ, Applegate RJ. Minimizing complications following stent implantation: outcomes and follow-up. Interv Cardiol 2013. [DOI: 10.2217/ica.13.24] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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18
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Meguro K, Ohira H, Nishikido T, Fujita M, Chinen T, Kikuchi T, Nakamura K, Keida T. Outcome of prolonged balloon inflation for the management of coronary perforation. J Cardiol 2013; 61:206-9. [PMID: 23380534 DOI: 10.1016/j.jjcc.2012.11.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2012] [Revised: 11/09/2012] [Accepted: 11/19/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND Coronary perforation (CP) is a rare, sometimes lethal complication of percutaneous coronary intervention (PCI). OBJECTIVES The purpose of this study was to review the cases of CP and to investigate the management after CP. METHODS A total of 3469 PCIs were performed in our institution from April 1999 to April 2008. All CP cases were identified from our computerized database. RESULTS Thirty patients were identified as having CP (0.86%). According to the Ellis classification, we determined the grade of perforation as type I in 17 cases (56%), type II in 2 cases (7%), and type III in 11 cases (37%). Most CPs were caused by wires (53%), while balloons, stents, and atherectomy devices were responsible for 7%, 37%, and 3%, respectively. Wire caused only 1 case of type III CP (6%), while stent caused 9 type III CPs (82%, p<0.01). Four patients (36%) with type III CP required urgent coronary artery bypass graft surgery (CABG), while no patient with type I/II CP required it (p<0.01). Prolonged balloon inflations were effective for 8 cases out of 11 stent CPs, however, the ballooning duration was significantly longer than that in wire and balloon CP (44±37min vs. 21±13min, p<0.05). CONCLUSIONS Stent CP often causes type III CP and one third of type III CP required urgent CABG. Although stent CP required longer balloon inflations for the management, prolonged balloon inflation might be useful for the management even in the stent CP.
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Affiliation(s)
- Kentaro Meguro
- Department of Cardiology, Edogawa Hospital, Tokyo, Japan.
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Huang QH, Zou C, Zhang YW, Zhao R, Nie JH, Liu JM. Vascular Perforation by Enterprise Stent During Stent-Assisted Coil Embolization for Intracranial Aneurysm. Cardiovasc Intervent Radiol 2012; 36:857-9. [DOI: 10.1007/s00270-012-0443-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2012] [Accepted: 06/09/2012] [Indexed: 11/28/2022]
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Ziakas A, Economou F, Feloukidis C, Kiratlidis K, Stiliadis I. Left anterior descending artery perforation treated with graft stenting combining dual catheter and side branch graft stenting techniques. Herz 2012; 37:913-6. [DOI: 10.1007/s00059-012-3645-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2012] [Revised: 05/21/2012] [Accepted: 05/22/2012] [Indexed: 11/28/2022]
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Hendry C, Fraser D, Eichhofer J, Mamas MA, Fath-Ordoubadi F, El-Omar M, Williams P. Coronary perforation in the drug-eluting stent era: incidence, risk factors, management and outcome: the UK experience. EUROINTERVENTION 2012; 8:79-86. [PMID: 22580251 DOI: 10.4244/eijv8i1a13] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS Coronary perforation during percutaneous coronary intervention (PCI) is associated with a high risk of mortality and morbidity. However there has been little data on perforation in the current era despite significant changes in PCI practice. We set out to identify incidence, risk factors and management strategies of coronary perforation in the current era. METHODS AND RESULTS We performed a retrospective analysis of the Manchester Heart Centre PCI database from June 2004 to May 2008. Detailed analysis of all cases of suspected perforation was undertaken by case note and angiographic review. Demographic data was collected regarding all patients undergoing intervention. A total of 12,729 coronary lesions were treated in 7,903 patients over four years, during which drug-eluting stent (DES) uptake was 77%. The incidence of perforation was 0.56% (44/12,729). Perforation was associated with an inpatient mortality of 15.9% (7/44). Factors associated with perforation were female sex (p=0.003), increasing age (p<0.01), coronary calcification (p=0.003), use of a cutting balloon (p<0.001) or atheroablation (p<0.001), and treatment of a chronic total occlusion (p<0.01). Factors associated with death after perforation were non-elective procedure (p=0.036) and pericardial drain insertion (p<0.001). CONCLUSIONS Despite treatment of more complex disease, the incidence of coronary perforation has not increased. Major perforations (Ellis class III) are associated with a high rate of emergency coronary artery bypass graft (CABG) and death. Endovascular treatments allow sealing of the perforation in most cases and deaths occur primarily as a result of cardiogenic shock due to occlusion of the culprit artery. Patient risk factors associated with perforation should be considered when planning or performing PCI.
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Affiliation(s)
- Cara Hendry
- Lancashire Cardiac Centre, Blackpool, United Kingdom
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Coronary Artery Perforation During Percutaneous Coronary Intervention: A Systematic Review and Meta-analysis. Can J Cardiol 2011; 27:843-50. [DOI: 10.1016/j.cjca.2011.04.014] [Citation(s) in RCA: 99] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2011] [Revised: 04/29/2011] [Accepted: 04/29/2011] [Indexed: 11/23/2022] Open
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Abdel-Wahab M, Richardt G. Safety of bivalirudin in patients with coronary artery disease. Expert Opin Drug Saf 2011; 11:141-50. [DOI: 10.1517/14740338.2012.628312] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Outcomes of coronary arterial perforations during percutaneous coronary intervention with bivalirudin anticoagulation. Am J Cardiol 2011; 108:932-5. [PMID: 21784388 DOI: 10.1016/j.amjcard.2011.05.025] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2011] [Revised: 05/17/2011] [Accepted: 05/17/2011] [Indexed: 11/21/2022]
Abstract
Coronary perforation (CP) is a rare but catastrophic event that may be influenced by the procedural anticoagulation regimen. This study compared the consequences of CP in patients who underwent anticoagulation with bivalirudin (BIV; a nonreversible direct thrombin inhibitor with a shorter 1/2-life than heparin) to those in patients who underwent anticoagulation with heparin (HEP) at time of CP. Patients with CP were identified from 33,613 procedures available in our institutional angioplasty registry. The outcome of this group was compared based on anticoagulation regimen (BIV vs HEP). The primary end point for this analysis was the composite of in-hospital death, cardiac tamponade, or emergency cardiac surgery. Overall a cohort of 69 patients (0.2%) with CP was identified. BIV was the intraprocedural anticoagulant in 41 patients, whereas HEP was used in 28. Baseline characteristics were comparable between groups except for a higher frequency of systemic hypertension and hypercholesterolemia in the BIV group. Procedural characteristics were also similar including lesion complexity and perforation severity. Nearly 1/2 of CPs in each group was managed with prolonged balloon inflation alone. Protamine was used in 46% of HEP-treated patients. Covered stents tended to be used more frequently in the BIV group (p = 0.061). The primary composite end point was similar between groups (odds ratio 1.42, 95% confidence interval 0.47 to 4.29, p = 0.53). However, there was a lower rate of cardiac surgery requirement in BIV-treated patients (p = 0.037). In conclusion, our study suggests that choice of procedural anticoagulant agent does not influence outcome when CP occurs. Therefore, use of BIV should not be discouraged in patients undergoing high-risk intervention for perforations.
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Kim JH, Kim MK, Kim YJ, Park SM, Park KH, Choi YJ. Is a metallic microcoil really a permanent embolic agent for the management of distal guidewire-induced coronary artery perforation? Korean Circ J 2011; 41:474-8. [PMID: 21949533 PMCID: PMC3173669 DOI: 10.4070/kcj.2011.41.8.474] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2011] [Accepted: 03/31/2011] [Indexed: 11/15/2022] Open
Abstract
Coronary artery perforation (CAP) after percutaneous coronary intervention is a rare, but serious complication. It can cause cardiac tamponade, acute myocardial infarction or death. The treatments of CAP involve prolonged balloon inflation, emergent surgery, coil embolization, and implantation of covered stent. We have successfully performed the emergent microcoil embolization in a patient with uncontrolled Ellis grade 3 guidewire-induced CAP resulting in delayed cardiac tamponade. Contrasting our usual expectation, the 1-year follow-up angiography showed a patent flow at the embolized site.
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Affiliation(s)
- Jae Hyun Kim
- Division of Cardiology, Department of Internal Medicine, Hallym University Medical School, Hangang Sacred Heart Hospital, Seoul, Korea
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Trana C, Muller O, Roguelov C, Eeckhout E. Deciding on the best course of action for grade III coronary perforations. Interv Cardiol 2011. [DOI: 10.2217/ica.11.40] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Morrison DA. Are we totally clear? Catheter Cardiovasc Interv 2009; 74:987-8. [PMID: 19953511 DOI: 10.1002/ccd.22335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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