Incidence, correlates, management, and clinical outcome of coronary perforation: analysis of 16,298 procedures

Influence of Previous Coronary Artery Bypass Grafting on Clinical Outcomes After Percutaneous Coronary Intervention: A Meta-Analysis of 250 684 Patients

Background

Percutaneous coronary intervention (PCI), also known as coronary angioplasty, is the preferred strategy for treating obstructive coronary artery disease. Existing literature suggests the worsening of clinical outcomes in patients with previous coronary artery bypass grafting (CABG) history. In light of this, a comprehensive systematic review and meta-analysis was performed.

Methods

Databases including PubMed, Cochrane Library, and ScienceDirect were utilized for the inclusive systematic search dating from inception to September 01, 2023. The risk of bias assessment was performed using the Newcastle-Ottawa scale for cohort studies, and the Cochrane Risk of Bias Tool for randomized controlled trials.

Results

Ultimately, there were 16 eligible studies pooled together, involving a total of 250 684 patients, including 231 552 CABG-naïve patients, and 19 132 patients with a prior history of CABG. Overall, patients with CABG history were associated with significantly greater short-term mortality (P = .004), long-term mortality (P = .005), myocardial infarction (P < .00001), major adverse cardiovascular events (P = .0001), and procedural perforation (P < .00001). Contrastingly, CABG-naïve patients were associated with significantly greater risk of cardiac tamponade (P = .02) and repeat CABG (P = .03). No significant differences in stroke, bleeding, revascularization, or repeat PCI were observed.

Conclusion

Comparatively worsened clinical outcomes were observed, as patients with prior CABG history typically exhibit complex coronary anatomy, and have higher rates of comorbidities in comparison to their CABG-naïve counterparts. The refinement of current procedural and surgical techniques, in conjunction with continued research endeavors, are needed in order to effectively address this trend.

Ellis type 4 coronary artery perforation during percutaneous coronary intervention: Case series and review

Ellis type 4 coronary artery perforation (CAP4), also referred to as Ellis type 3 cavity-spilling perforation, is a rare but life-threatening complication of percutaneous coronary intervention characterized by extravasation of blood into a cardiac chamber, anatomic cavity, or coronary sinus or vessel. CAP4 is uncommon, accounting for 1.9% to 3.0% of all CAP. Only 11 cases of CAP4 have been reported in detail; we report an additional two cases and review prior reports of this rare complication. Our first case highlights a patient with chronic anginal symptoms due to a 75% concentric stenotic lesion in the mid-LAD. Revascularization was complicated by perforation during pre-dilation with robust contrast extravasation into the left ventricle. Successful postperforation hemostasis was achieved with heparin reversal and covered stent placement. The second case demonstrates another major mechanism of CAP4: wire perforation. During intervention, the absence of blood flow distal to the lesion in the setting of an ST segment elevation myocardial infarction obscured the course of the nonhydrophilic floppy wire leading to perforation that was managed conservatively. In our scoping review, we found that the majority of CAP4 occurred in the LAD. The most frequently involved cavity was the left ventricle-other cavities involved were the right ventricle and coronary veins. Common etiologies of CAP4 included guidewire perforation (62%) and balloon dilation (31%). Perforation was managed with reversal of anticoagulation in 46% of cases, prolonged balloon inflation in 54% of cases, and covered stent deployment in 15% of cases. No patients required surgical repair or pericardiocentesis and perforations were successfully sealed in all cases. In-hospital mortality was 0%.

Gender-Based Differences in Outcomes After Percutaneous Coronary Intervention of Chronic Total Occlusions (Insights from a Large Single-Center Registry)

Patients who undergo percutaneous coronary intervention (PCI) of chronic total occlusions (CTO) are at a high risk for both periprocedural and post-procedural adverse events. Whether gender-differences in outcomes exist after PCI of CTO remain unclear. Therefore, we sought to investigate gender-based differences in outcomes after CTO-PCI. All patients who underwent elective CTO intervention from January 2012 to December 2017 at The Mount Sinai Hospital (New York, New York) were included. The primary end point of interest was major adverse cardiac events defined as the composite of death, myocardial infarction, and target vessel revascularization at 1 year of follow-up. A total 1,897 patients were included, of which 368 were women (19.4%). Mean follow-up time was 174 days. Women were older (66.8 ± 11.3 years vs 62.6 ± 10.9 years) and had a higher prevalence of co-morbidities including diabetes and chronic kidney disease. There were no significant differences in the rate of successful CTO-PCI between groups (73.5% vs 73.2%, p = 0.91). Women had higher rates of procedure-related complications including increased risk of post-procedural bleeding (4.1% vs 1.8%, p = 0.009) and acute vessel closure (1.36% vs 0.2%, p = 0.009). In multivariable-adjusted analysis, female gender was associated with higher risk of major adverse cardiac event and target vessel revascularization at 1 year. In conclusion, in this large single-center study, women who underwent percutaneous CTO revascularization experienced higher rates of periprocedural complications and worse clinical outcomes at 1 year compared with men. Further research is needed to address disparities in gender-specific outcomes of CTO-PCI.

Coils embolization use for coronary procedures: Basics, indications, and techniques

The use of coils is fundamental in interventional cardiology and can be lifesaving in selected settings. Coils are classified by their materials into bare metal, fiber coated, and hydrogel coated, or by the deliverability method into, pushable or detachable coils. Coils are delivered through microcatheters and the choice of coil size is important to ensure compatibility with the inner diameter of the delivery catheter, firstly to be able to deliver and secondly to prevent the coil from being stuck and damaged. Clinically, coils are used in either acute or in elective setting. The most important acute indication is typically the sealing coronary perforation. In the elective settings, coils can be used for the treatment of certain congenital cardiac abnormalities, aneurysms, fistulas or in the treatment of arterial side branch steal syndrome after CABG. Coils must always be delivered under fluoroscopy guidance. There are some associated complications with coils that can be acute or chronic, that nictitates regular followed-up. There is a need for education, training and regular workshops with hands-on to build the experience to use coils in situations that are infrequently encountered.

A Novel Strategy for Emergency Treatment of Coronary Perforations by Placing a Drug-Eluting Stent before Sealing off the Leakage with a Covered Stent to Improve Long-Term Outcomes in Patients with Coronary Artery Perforations

We aimed to investigate the safety, feasibility, and long-term results of drug-eluting stent implantation before covered stents for treating coronary artery perforation (CAP). Between 2015 and 2020, 12,733 patients undergoing percutaneous coronary intervention (PCI) were retrospectively analyzed. The primary endpoint was 1-year target lesion revascularization (TLR), whereas secondary endpoints included the rate of major adverse cardiac and cerebrovascular events (MACCE) and all-cause death at 1 year. A total of 159 patients with CAP were identified during the study period, of whom 47.2% (n = 75) were treated with a covered stent (CS group) because of complex and/or severe CAP and 84 (52.8%) without (non-CS group). In the majority of patients, emergency drug-eluting stent placement before covered stent implantation was feasible (n = 69, 82%). There were no significant differences among patients treated with or without a covered stent in terms of primary or secondary clinical endpoints: a similar rate of TLR (18.67% vs. 21.43%, p = 0.6646), MACCE (25.33% vs. 22.62%, p = 0.6887), and 1-year mortality (12.00% vs. 11.90%, p = 0.9853) were identified comparing cases with covered stent implantation and without. In conclusion, our study implicates that the use of covered stents for sealing coronary perforation might not impact the 1-year clinical outcome if used properly. Moreover, the emergent use of drug-eluting stents before covered stent implantation in CAP is a safe and effective method to avoid target lesion revascularization in patients treated with covered stents.

The contemporary role of protamine in the cardiac catheterization laboratory

Access to the arterial circulation and full anticoagulation carries a risk of serious bleeding during and after percutaneous coronary intervention. Important sources of bleeding include the arterial access site and coronary artery perforation. Prompt and effective management of hemorrhagic complications is an essential interventional skill. Protamine sulfate is well-known as a heparin reversal agent. Despite this, there is heterogeneity in the use of protamine during interventional procedures. While protamine is generally well-tolerated, it is associated with a risk of hypersensitivity reaction, including anaphylaxis, among others. The purpose of this review is to summarize the existing evidence about and experience with the use of protamine sulfate in the setting of percutaneous coronary and structural interventional procedures.

Bail-Out Techniques in Percutaneous Intervention for Ellis Grade III Coronary Perforation in Left Main Distal Bifurcation Lesions

The left main (LM) coronary artery stenosis is associated with high morbidity and mortality and has traditionally been treated with coronary artery bypass grafting. However, in recent years, advancements in device technology and adjunctive pharmacotherapy have led to the widespread use of percutaneous coronary intervention (PCI) as a treatment for unprotected LM lesions. Despite this, LM lesions are often complex, involving distal bifurcation and heavy calcification, which increases the risk of coronary perforation (CP) during PCI. In addition, the use of rotational or orbital atherectomy in severely calcified LM bifurcation lesions carries a higher risk of complications and in-hospital mortality than that in non-LM lesions. CP is a rare but potentially fatal complication of PCI, particularly in cases of Ellis grade III (CP-G3), with a high rate of cardiac tamponade and mortality. The management of CP-G3 in LM distal bifurcation lesions is challenging and requires specialized techniques. This article presents a flowchart of bail-out strategies for CP-G3 in LM distal bifurcation lesions and provides detailed procedures for each technique. Furthermore, we highlight the challenges and limitations of each technique, requiring careful management when CP-G3 occurs in LM distal bifurcation lesions.

Coronary perforation incidence, outcomes and temporal trends (COPIT): a systematic review and meta-analysis

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.

Changing trends in the incidence, management and outcomes of coronary artery perforation over an 11-year period: single-centre experience

Introduction

Coronary artery perforation (CP) is a rare but life-threatening complication of percutaneous coronary intervention (PCI). This study aimed to assess the incidence, management and outcomes of CP over time.

Methods

A single-centre retrospective cohort study of all PCIs performed between January 2010 and December 2020. Patients with CP were divided into two cohorts (A+B), representing the two halves of the 11-year study.

Results

The incidence of CP was 68 of 9701 (0.7%), with an increasing trend over the two 5.5-year periods studied (24 of 4661 (0.5%) vs 44 of 5040 (0.9%); p=0.035). Factors associated with CP included chronic total occlusions (CTOs) (16 of 68 (24%) vs 993 of 9633 (10%); p<0.001), type C lesions (44 of 68 (65%) vs 4280 of 9633 (44%); p<0.001), use of intravascular ultrasound (IVUS) (12 of 68 (18%) vs 541 of 9633 (6%); p<0.001), cutting balloon angioplasty (3 of 68 (4%) vs 98 of 9633 (1%); p<0.001) and hydrophilic wires (24 of 68 (35%) vs 1454 of 9633 (15%); p<0.001). Cohorts A and B were well matched with respect to age (69±11 vs 70±12 years; p=0.843), sex (males: 13 of 24 (54%) vs 31 of 44 (70%); p=0.179) and renal function (chronic kidney disease: 1 of 24 (4%) vs 4 of 44 (9%); p=0.457). In cohort A, CP was most frequently caused by post-dilatation with non-compliant balloons (10 of 24 (42%); p=0.009); whereas in cohort B, common causes included guidewire exits (23 of 44 (52%)), followed by stent implantation (10 of 44 (23%)). The most common treatment modality in cohorts A and B was balloon inflation, which accounted for 16 of 24 (67%) and 13 of 44 (30%), respectively. The use of covered stents (16%) and coronary coils (18%) during cohort B study period did not impact all-cause mortality, which occurred in 2 of 24 (8%) and 7 of 44 (16%) (p=0.378) in cohorts A and B, respectively.

Conclusion

The incidence of CP is increasing as more complex PCI is performed. Factors associated with perforation include CTO or type C lesions and use of IVUS, cutting balloon angioplasty or hydrophilic wires.

Technique for Salvage Reconstruction of Shredded Left Main Coronary Artery after Rotablator Injury

We report the technique needed to effectively repair a left main coronary artery shredding after rotational atherectomy and destruction of the left main coronary artery. The patient had been deemed inoperable at another center because of diffuse distal coronary disease. The complication led to cardiac tamponade and hemodynamic collapse, necessitating cardiopulmonary resuscitation and salvage surgery. This is perhaps the first case in the literature to show a successful repair of such a complex and significant left main, left anterior descending, and left circumflex coronary artery rupture in a patient in extremis.

[Focus on high speed rotational atherectomy by Rotablator in 2021 and datas from France PCI registry]

Developed in the late 1980s, rotational atherectomy has raised a lot of hope for its innovative principle of selective ablation, allowing volume reduction (instead of redistribution) of atherosclerotic plaque, while sparing healthy tissue. Long shunned for its disappointing results on restenosis, the Rotablator finally reasserted itself in the 2000s; era of drug eluting stents and coronary angioplasty boom, thus generating emergence of complex lesions. Indeed, the Rotablator has demonstrated an undeniable benefit in complex (type C) and calcified lesions preparation (before stenting), with a procedural success rate of 95%. Although these lesions only represent a small amount (2-3%) of percutaneous coronary interventions (PCI), they remain a technical impasse for plain-old balloon angioplasty strategy, making the Rotablator more suitable for these resistant lesions' treatment. Registry data attest the safety of this therapy, with a rate of peri-procedural complications and in-hospital mortality comparable to conventional angioplasty (France PCI register). However, certain specific, rare but serious complications (burr entrapment, broken Rotawire, coronary perforation) justify trained teams, perfect knowledge of the equipment, and strict compliance with good practice guidelines. In 2018, the rise of a new method of atherectomy by intra-vascular lithotripsy (Shockwave) has coincided with Rotablator decreasing activity (this finding being biased by a general decrease in PCI activity due to Covid pandemic). This therapeutic range's enhancement revolutionizes calcified lesions treatment, tending towards precise targeting of each indication, depending in particular on calcium distribution's anatomy in the plaque.

Prevalence, management and outcomes of cardiac tamponade complicating 66,812 invasive cardiac procedures: single-center clinical registry

Introduction

There are numerous studies concerning iatrogenic cardiac tamponade. Those studies are predominantly focused on one cardiac procedure and the follow-up is not always presented.

Aim

To estimate the rate of cardiac tamponade following 66,812 percutaneous invasive cardiac interventions depending on the procedure. For each group the baseline characteristics and hospital management, as well as in-hospital, 30-day and 1-year mortality, were evaluated.

Material and methods

The study was a single-center retrospective analysis performed in a tertiary clinical hospital, which encompasses two cardiology departments, assessing a large sample of patients who underwent percutaneous invasive cardiac procedures complicated with cardiac tamponade between January 2006 and December 2018. For this purpose, medical records and hospital databases were analyzed. Long-term follow-up was obtained in cooperation with the Silesian Cardiovascular Base.

Results

The rate of iatrogenic cardiac tamponade during the 13-year period was 0.176%. The incidence among selected invasive cardiac procedures ranged between 0.09% and 1.42%. The majority of cases (104/118) were treated by pericardiocentesis, 16 had pericardiotomy and 4 patients had both therapies. Inotropes were used in 25–45%, blood transfusion in 45% of patients. The highest in-hospital mortality was observed in patients with cardiac tamponade after transcatheter aortic valve implantation. The highest 30-day and 1-year mortality rates were seen in the group with temporary electrode pacing.

Conclusions

The low incidence of cardiac tamponade with the high number of patients requiring intensive care supply and high in-hospital mortality tend to confirm that cardiac tamponade is a rare but life-threatening complication.

The prevalence, management and outcomes of coronary artery perforations during percutaneous coronary intervention in patients with or without acute coronary syndromes

BACKGROUND

Coronary artery perforation (CAP) is an uncommon but serious complication of percutaneous coronary intervention (PCI). The aim of this study was to compare early and late clinical outcomes of CAP in patients with or without acute coronary syndromes (ACS).

METHOD

A retrospective review was made of the procedural records of 15 878 patients who underwent PCI at two large tertiary centers between January 2012 and December 2018. A total of 51 (0.32 %) CAP cases were identified.

RESULTS

Of the 51 CAP cases, 26 (51.0%) patients had ACS and 25 (49%) patients had stable coronary artery disease (CAD). The major cause of perforation was stenting (43%). Cardiac tamponade was more frequent in the ACS group than stable CAD group (34.6 vs. 8%; P = 0.024). Kaplan-Meier analysis showed that the overall 30-day cardiovascular mortality rate was higher in patients with ACS than stable CAD (23.1 vs. 0%; P = 0.011). At the 3-year follow-up examination, no statistically significant difference was determined between the two groups in respect of all-cause mortality (36.1 vs. 28.4%; P = 0.262). Multivariable Cox regression analysis demonstrated left ventricular ejection fraction (hazard ratio, 0.94; 95% CI, 0.89-0.99; P = 0.033) but not ACS at presentation (hazard ratio, 1.39; 95% CI, 0.37-5.20; P = 0.628) as a predictor of mortality at 3 years.

CONCLUSIONS

Early clinical outcomes following CAP, including cardiac tamponade and 30-day cardiovascular mortality, were significantly worse in patients with ACS compared to stable CAD.

The Efficacy and Safety of Nicorandil for Periprocedural Myocardial Injury in Patients Undergoing PCI: A Meta-Analysis

Purpose

To evaluate the efficacy and safety of nicorandil for periprocedural myocardial injury in patients undergoing PCI through meta-analysis of randomized controlled trials.

Methods

We analyzed the clinical data of patients including the incidence of periprocedural myocardial injury (PMI) and major adverse cardiovascular events (MACE) from selected articles. RCTs were retrieved from medical literature databases. RR and 95% confidence intervals (CI) were calculated to compare the endpoints.

Results

In total, 15 articles (16 trial comparisons) were retrieved which contained 2221 patients. In general, 1130 patients (50.9%) were randomized to the experimental group, whereas 1091 patients (49.1%) were randomized to the control group. The result showed that nicorandil significantly reduced the incidence of PMI and MACE after PCI compared to the control group.

Conclusions

Overall, early use of nicorandil in patients undergoing percutaneous coronary intervention (PCI) was associated with a significant reduction of PMI and MACE.

Urgent Pericardiocentesis Is More Frequently Needed After Left Circumflex Coronary Artery Perforation

Background: Coronary artery perforation (CAP) is a rare but potentially life-threatening complication of percutaneous coronary interventions (PCIs) due to the risk of cardiac tamponade. Strikingly, in contrast to numerous analyses of CAP predictors, only few studies were focused on the predictors of tamponade after PCI, once iatrogenic CAP has occurred. Our aim was to search for clinical and periprocedural characteristics, including the coronary artery involved, associated with the development of acute cardiac tamponade among patients experiencing CAP. Methods: From the medical records of nine centers of invasive cardiology in southern Poland, we retrospectively selected 81 patients (80% with acute myocardial infarction) who had iatrogenic CAP with a visible extravasation jet during angiography (corresponding to type III CAP by the Ellis classification, CAP_III) over a 15-year period (2005-2019). Clinical, angiographic and periprocedural characteristics were compared between the patients who developed acute cardiac tamponade requiring urgent pericardiocentesis in the cathlab (n = 21) and those with CAP_III and without tamponade (n = 60). Results: CAP_III were situated in the left anterior descending artery (LAD) or its diagonal branches (51%, n = 41), right coronary artery (RCA) (24%, n = 19), left circumflex coronary artery (LCx) (16%, n = 13), its obtuse marginal branches (7%, n = 6) and left main coronary artery (2%, n = 2). Acute cardiac tamponade occurred in 24% (10 of 41), 21% (4 of 19) and 37% (7 of 19) patients who experienced CAP_III in the territory of LAD, RCA and LCx, respectively. There were no significant differences in the need for urgent pericardiocentesis (37%) in patients with CAP_III in LCx territory (i.e., the LCx or its obtuse marginal branches) compared to CAP_III in the remaining coronary arteries (23%) (p = 0.24). However, when CAP_III in the LCx were separated from CAP_III in obtuse marginal branches, urgent pericardiocentesis was more frequently performed in patients with CAP_III in the LCx (54%, 7 of 13) compared to subjects with CAP_III in an artery other than the LCx (21%, 14 of 68) (p = 0.03). The direction of this tendency remained consistent regardless of CAP management: prolonged balloon inflation only (n = 26, 67% vs. 13%, p = 0.08) or balloon inflation with subsequent stent implantation (n = 55, 50% vs. 24%, p = 0.13). Besides LCx involvement, no significant differences in other characteristics were observed between patients according to the need of urgent pericardiocentesis. Conclusions: CAP_III in the LCx appears to lead to a higher risk of acute cardiac tamponade compared to perforations involving other coronary arteries. This association may possibly be linked to distinct features of LCx anatomy and/or well-recognized delays in diagnosis and management of LCx-related acute coronary syndromes.

Rotational Atherectomy Induced Coronary Perforation of Right Coronary Artery Draining into Middle Cardiac Vein

Ellis Type III cavity spilling coronary perforation is a rare complication. We report to our knowledge, the first case of rotational atherectomy induced Type III cavity spilling coronary perforation of right posterior descending artery draining into middle cardiac vein, successfully managed by covered stent deployment. (Level of Difficulty: Advanced.)

A Novel Approach to Subcutaneous Collecting Lymph Ducts Using a Small Diameter Wire in Animal Experiments and Clinical Trials

Background: While performing microsurgery, including lymphaticovenous anastomosis (LVA) for chronic limb lymphedema, it is a common procedure to identify the subcutaneous collecting lymph ducts with near-infrared fluorescence lymphangiography (NIR) using indocyanine green. However, due to limitations such as minimum observable depth, only a few lymphatic ducts can be identified with this procedure. Hence, we developed a new smaller-diameter "lymphatic wire" (LW) that could be inserted directly into lymphatic collecting ducts of the limbs, enabling accurate identification and localization. Methods and Results: First, used the LW on the hind limbs of 6 swine, and 36 porcine lymphatic collecting ducts were identified, the outer diameter of which varied from 0.3-0.7 mm (mean 0.41 ± 0.11 mm). We could insert the LW after creating a side opening in 30 of these ducts. We encountered no difficulties during the procedure. In the pathological examination, adverse events such as valve dysfunction and perforation were not identified. Based on the results, a clinical evaluation of the LW was performed in two patients with lower extremity lymphedema, and the LW helped us identify lymphatic ducts in the subcutaneous layer, even at the sites where the NIR had proved ineffective. Conclusion: Based on our results, we suggest that the procedure for identifying lymphatic vessels using the newly developed LW is a useful technique that can be utilized before performing a LVA for lymphedema. However, further clinical study is required to develop this device and technique, for wider clinical application in the future.

"Incidence, clinical and angiographic characteristics, management and outcomes of coronary artery perforation at a high volume cardiac care center during percutaneous coronary intervention"

AIMS

To study the incidence, clinical and angiographic characteristics, management and outcomes of coronary artery perforation (CAP) during percutaneous coronary intervention (PCI) at a high volume center in South-east Asia.

METHODS

Data from patients who had CAP during PCI from January 2016 to December 2019 at our center were collected. Clinical features, angiographic and procedural characteristics, their management and outcomes were analyzed retrospectively.

RESULTS

A total of 40,696 patients underwent PCI during the study period and the incidence of CAP was 0.13% (n = 51). Mean age was 60.0 ± 10.8 years and 69% were males. CAP cases involved complex type B2/C lesions in 73%, calcified lesions in 58%, and chronic total occlusions in 25%. Majority of patients presented as acute coronary syndrome (65%) and STEMI was the most frequent indication for PCI (33%). Most of the CAPs were Ellis type II (33%) and III (55%). CAP most frequently occurred during post dilation (n = 20) and wire manipulation (n = 17). Majority were treated by prolonged balloon inflation (53%) and covered stents (33%). Pericardiocentesis was required in 19 patients to alleviate tamponade. In one patient coil embolisation was done and two patients required bail-out emergency cardiac surgery. Periprocedural myocardial infarction occurred in 6% and in-hospital mortality was 10%. All-cause mortality accrued to 14% at 30 days and 16% at 6 months.

CONCLUSION

Although incidence of CAP in contemporary interventional practice remains low, the morbidity and mortality are considerable. Early recognition and management strategies tailored to the severity of perforation play a key role in achieving better outcomes.

Pericardial tamponade as a complication of invasive cardiac procedures: a review of the literature

Cardiac tamponade (CT) is a rare but often life-threatening complication after invasive cardiac procedures. Some procedures favor CT. Furthermore, the incidence depends on patients’ comorbidities, sex and age and operators’ skills. In this paper we review studies and meta-analyses concerning the rate of iatrogenic CT. We define the risk factors of CT and show concise characteristics for each invasive cardiac procedure separately. According to our analysis CT occurs especially after procedures requiring transseptal puncture or perioperative anticoagulation. The overall rate of CT after such procedures varies among published studies from 0.089% to 4.8%. For this purpose we searched the PubMed database for clinical studies published up to December 2018. We included only those studies in which a defined minimum of procedures were performed (1000 for atrial fibrillation ablation, 6000 for percutaneous coronary intervention, 900 for permanent heart rhythm devices, 90 for left atrial appendage closure, 300 for transcatheter aortic valve implantation and percutaneous mitral valve repair with the Mitra-Clip system). The search was structured around the key words and variants of these terms. In addition, secondary source documents were identified by manual review of reference lists, review articles and guidelines. The search was limited to humans and adults (18+ years).

A Practical Approach to the Management of Complications During Percutaneous Coronary Intervention

Percutaneous coronary intervention relieves symptoms in patients with chronic ischemic heart disease resistant to optimal medical therapy and alters the natural history of acute coronary syndromes. However, adverse procedural outcomes may occur during the intervention. Knowledge of possible complications and their timely management are essential for the practicing cardiologist and can be life-saving for the patient. In this review, the authors summarize potential complications of percutaneous coronary intervention focusing on their practical management.

Prevalence and Predictors of Coronary Artery Perforation During Percutaneous Coronary Interventions (from the ORPKI National Registry in Poland)

Coronary artery perforation (CAP) is a rare but potentially life-threatening complication of percutaneous coronary intervention (PCI). With a growing number of PCIs in complex lesions, the problem of CAP becomes even more important nowadays. Data on CAP rates in Poland are lacking. Presented study is an analysis of 344,517 consecutive patients treated with PCI between 2014 and 2017. Data were gathered from the Polish National PCI Registry (ORPKI). During 4 years of data collection CAP was observed in 595 (0.17%) cases. Patients diagnosed with CAP were older (69 years Q1:63; Q3:78 vs 66 years Q1:60; Q3:75; p <0.001), more often female (44% vs 32%; p <0.001), with arterial hypertension (77% vs 71%; p = 0.002), and chronic kidney disease (8.9% vs 5.4%; p <0.001). In the CAP group, a higher rate of PCIs within chronic total occlusions (8.7% vs 2.3%; p <0.001) and saphenous vein graft lesions (2.7% vs 1.3%; p = 0.002), as well as rotational atherectomy procedures (2.2% vs 0.4%; p <0.001) was observed. Patients with CAP had higher rate of no-reflow phenomenon (5.5% vs 0.5%; p <0.001) and greater periprocedural mortality (4.2% vs 0.5%; p <0.001). In conclusion, our study confirms that CAP is more common during complex PCI procedures in high-risk patients. CAP occurrence is associated with worse immediate outcomes including increased periprocedural mortality.

Very long-term outcome of coronary covered stents: a report from the SCAAR registry

AIMS

Covered stents are mostly used for coronary perforations with a high risk of early adverse events; however, their long-term outcome is unknown. The aim of this study was to elucidate the short- and long-term outcome of patients treated with covered stents compared to all other stented patients.

METHODS AND RESULTS

The Swedish national registries from 2005-2017 disclosed 265 patients who had received 366 covered stents. Their outcomes were compared to all other stented patients (197,948) who had received 320,784 stents. Compared to regular stents, covered stents showed significant differences (p<0.001) in the short and long term in relation to in-stent restenosis (ISR), target lesion revascularisation (TLR), re-infarction (MI), re-PCI and mortality, the rates of which were all higher. The higher mortality was concentrated within the first month, as a landmark analysis at that time point, adjusted for age and procedural indication, demonstrated no future difference in mortality (HR 1.02 [0.78-1.33], p=0.877). Stent thrombosis (ST) within one year was reported to be higher in covered stents than in other stents. However, no ST was reported in equine pericardial covered stents.

CONCLUSIONS

This observational study including the entire Swedish population shows that patients receiving covered stents have a significantly higher risk of all adverse events. Reassuringly, in the long term, mortality appears to be similar to that in other stented patients.

Coronary perforation complicating percutaneous coronary intervention in patients presenting with an acute coronary syndrome: An analysis of 1013 perforation cases from the British Cardiovascular Intervention Society database

BACKGROUND

The evidence base for coronary perforation occurring during percutaneous coronary intervention in patients presenting with an acute coronary syndrome (ACS-PCI) is limited and the specific role of acute pharmacology in its clinical presentation unclear.

METHODS AND RESULTS

Using the BCIS PCI database, data were analysed on all ACS-PCI procedures performed in England and Wales between 2007 and 2014. Multiple regressions were used to identify predictors of coronary perforation and its association with outcomes. Propensity score matching was used to evaluate the association between differing P2Y12 inhibitors or glycoprotein inhibitors (GPI) and CP. During 270,329 ACS-PCI procedures, 1013 coronary perforations were recorded (0.37%) with a stable annual incidence. In multiple regression analysis, covariates associated with increased frequency of coronary perforation included age, female gender, CTO intervention, number and length of stents used, and rotational atherectomy use, whilst differing P2Y12 inhibitors were not predictive. Using propensity score matching, use of a GPI was independently associated with tamponade (OR 1.50, [1.08-2.06], p = 0.014). The adjusted odds ratios for all clinical outcomes were adversely affected by coronary perforation.

CONCLUSIONS

Coronary perforation is an infrequent event during ACS-PCI but is closely associated with adverse clinical outcomes. GPI use was associated with higher rates of tamponade.

PK Papyrus covered stent: Device description and early experience for the treatment of coronary artery perforations

BACKGROUND

Coronary artery perforation during percutaneous revascularization is associated with considerable morbidity and mortality. The PK Papyrus covered stent provides a physical barrier to seal perforated arteries and prevent associated complications including death.

METHODS

In a survey of patients treated for coronary artery perforation with the PK Papyrus stent in 16 countries, procedural and in-hospital outcomes were ascertained. Procedural variables included device delivery, sealing of the perforation, and complications related to the covered stent.

RESULTS

Among 80 patients with coronary perforation, Ellis classification was characterized as grade III or III-cavity spilling in 50.0% and 17.5% of events, respectively. The mean (±SD) number of stents attempted for use per patient was 1.25 ± 0.61. The PK Papyrus stent was successfully delivered to the site of perforation in 76 patients (95.0%), and successful sealing was reported in 73 patients (91.3%). Pericardiocentesis was performed in seven patients (8.8%), and in-hospital death occurred in eight patients (10.0%). Among patient deaths, Ellis grade III perforations were reported in all instances (data not reported in one patient), and two cases were associated with unsuccessful sealing of the perforation site.

CONCLUSIONS

The PK Papyrus covered stent is designed to overcome limitations of existing therapies and to facilitate device delivery and effectively treat coronary artery perforations. Initial experience demonstrates favorably high rates of successful delivery to and sealing of the perforation site. Despite treatment, in-hospital mortality remains high for patients experiencing Ellis grade III coronary perforations.

Novel approach to coronary artery perforation repair

Coronary artery perforation (CAP) during percutaneous coronary intervention is a rare but serious complication. Treatment options of CAP include prolonged balloon inflation, covered stent, and coil embolization. Although most cases of CAP can be treated with prolonged balloon inflation, some cases, especially Ellis grade III CAP require covered stents or coiling. Covered stents may require a large bore guide catheter and have a high rate of restenosis, which can be a limiting factor in patients with severe peripheral arterial disease. Coil embolization is generally used in distal CAP because coiling in the proximal vessels results in a large territory of infarction. We present a case of an Ellis grade III CAP during rotational atherectomy successfully treated with a novel coiling technique whereby the thrombogenic coil extends through the perforation outside of the vessel, and the intraarterial portion of the coil is excluded from the lumen by drug-eluting stent placement over the proximal portion of the coil.

Spontaneous closure of an iatrogenic coronary artery fistula during recanalization of a chronic total occlusion lesion: A case report

RATIONALE

Coronary perforation leading to fistula directed to the right ventricle is a rare complication of percutaneous coronary intervention (PCI). The reported outcomes vary from a stable state to rapid deterioration.

PATIENT CONCERNS

An 86-year-old man was diagnosed with non-ST elevation myocardial infarction, and arranged to PCI procedure for the chronic total occluded right coronary artery (RCA) after coronary angiography. The guide wire went through the occluded lesion and got to the distal part of the suspected "post lateral artery", which later proved to be in the right ventricle (RV). After dilating with a 2.0 mm balloon, large amount of contrast medium leaked out from the lesion; therefore, we suspected a perforation into the pericardium.

INTERVENTION

Protamine was intravenously injected to convert the effect of heparin and the 2.0 mm balloon in diameter was dilated for about 1 h to obstruct the ejected blood flow shunting into the pericardium, but the leakage persisted. Nevertheless, the patient remained stable, and we were unable to detect an effusion in the pericardium.

DIAGNOSIS

By analyzing the angiogram and echocardiogram, we found that the contrast did not leak into the pericardium, but into the right ventricle (RV) chamber. An iatrogenic coronary artery fistula (ICAF) from the RCA to the RV was confirmed. We thus terminated the procedure.

OUTCOMES

Coronary computed tomography (CT) angiography was performed 2 days after the PCI and no abnormal shunt was found. There was no abnormal Doppler signal in the RV, either. The patient was soon discharged, and there have been no complaints of discomfort during the 10-month follow-up.

LESSONS

ICAFs from coronary to the RV always have favorable outcomes. Even like the one in this case that caused medium leakage could seal spontaneously without any additional management. Echocardiography or coronary CT angiography could be chosen as imaging options to follow-up ICAFs.

Outcome after new generation single-layer polytetrafluoroethylene-covered stent implantation for the treatment of coronary artery perforation

AIMS

Coronary artery perforation (CAP) is a rare but severe complication during percutaneous coronary intervention (PCI). Implantation of covered stents (CS) represents a potentially life-saving treatment. Concerns exist regarding limited efficacy and high stent thrombosis (ST) rates related to early generation CS. The aim of this study was to evaluate angiographic and clinical outcomes of patients with CAP treated with a new generation single-layer polytetrafluoroethylene (PTFE)-CS.

METHODS

Between May 2013 and November 2017, we identified a total of 61 patients who underwent implantation of 71 single layer PTFE-CS after CAP. We analyzed angiographic results at follow up (including binary angiographic restenosis [BAR] and late-lumen-loss [LLL]) and clinical outcomes in hospital and at follow up, including target lesion revascularization (TLR), cardiovascular-, and all-cause mortality, myocardial infarction (MI) and stent thrombosis (ST).

RESULTS

Procedural success was achieved in all but two patients (96.7%). Procedure related MI, occurred in 19 cases (31.1%), in hospital death occurred in five cases (8.2%). At follow-up, TLR occurred in 11 cases (18.0%), two patients (3.3%) died from non-cardiovascular cause, there was no case of MI or ST.

CONCLUSIONS

In this retrospective analysis, implantation of a new generation PTFE-CS, for the treatment of CAP showed high technical success rates. Although, periprocedural MI-and in-hospital-death rates remain not inconsiderable, new generation PTFE-CS showed favorable angiographic and clinical efficacy and high safety profile, especially with regard to thrombotic events.

Sex-Based Differences in Chronic Total Occlusion Management

ᅟ: Chronic total occlusions (CTOs) are an important and increasingly recognized subgroup of coronary lesions, documented in at least 30%, but up to 52% of patients with coronary artery disease (CAD) undergoing coronary angiography. Percutaneous coronary intervention (PCI) of these lesions is increasingly pursued, with excellent success rates. PURPOSE OF REVIEW: It is known that gender differences exist in the presentation of CAD, as well as in clinical outcomes after routine PCI; however, it is not well described how these differences pertain to management of CTOs. This review summarizes the available data regarding sex-based differences in CTO management and outcomes. RECENT FINDINGS: Women comprise approximately 20% of CTO registry and trial participants. As has been demonstrated in PCI studies, women comprise a minority of patients in CTO PCI registries and trials. Sex-based differences exist in complication rates, collateral formation, and outcomes and need further evaluation in future studies.

Anesthetic management of endovascular treatment for acute ischemic stroke: Influences on outcome and complications

Background and objectives

The emerging use of endovascular therapies for acute ischemic stroke, like intra-arterial thrombectomy, compels a better understanding of the anesthetic management required and its impact in global outcomes. This article reviews the available data on the anesthetic management of endovascular treatment, comparing general anesthesia with conscious sedation, the most used modalities, in terms of anesthetic induction and procedure duration, patient mobility, occlusion location, hemodynamic parameters, outcome and safety; it also focuses on the state-of-the-art on physiologic and pharmacologic neuroprotection.

Contents

Most of the evidence on this topic is retrospective and contradictory, with only three small randomized studies to date. Conscious sedation was frequently associated with better outcomes, but the prospective evidence declared that it has no advantage over general anesthesia concerning that issue. Conscious sedation is at least as safe as general anesthesia for the endovascular treatment of acute ischemic stroke, with equivalent mortality and fewer complications like pneumonia, hypotension or extubation difficulties. It has, however, a higher frequency of patient agitation and movement, which is the main cause for conversion to general anesthesia.

Conclusions

General anesthesia and conscious sedation are both safe alternatives for anesthetic management of patients submitted to endovascular thrombectomy. No anesthetic management is universally recommended and hopefully the ongoing randomized clinical trials will shed some light on the best approach; meanwhile, the choice of anesthesia should be based on the patient's individual characteristics. Regarding neuroprotection, hemodynamic stability is currently the most important strategy, as no pharmacological method has been proven effective in humans.

Incidence, predictors, management and outcomes of coronary perforations

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.

[Anesthetic management of endovascular treatment for acute ischemic stroke: Influences on outcome and complications]

BACKGROUND AND OBJECTIVES

The emerging use of endovascular therapies for acute ischemic stroke, like intra-arterial thrombectomy, compels a better understanding of the anesthetic management required and its impact in global outcomes. This article reviews the available data on the anesthetic management of endovascular treatment, comparing general anesthesia with conscious sedation, the most used modalities, in terms of anesthetic induction and procedure duration, patient mobility, occlusion location, hemodynamic parameters, outcome and safety; it also focuses on the state-of-the-art on physiologic and pharmacologic neuroprotection.

CONTENTS

Most of the evidence on this topic is retrospective and contradictory, with only three small randomized studies to date. Conscious sedation was frequently associated with better outcomes, but the prospective evidence declared that it has no advantage over general anesthesia concerning that issue. Conscious sedation is at least as safe as general anesthesia for the endovascular treatment of acute ischemic stroke, with equivalent mortality and fewer complications like pneumonia, hypotension or extubation difficulties. It has, however, a higher frequency of patient agitation and movement, which is the main cause for conversion to general anesthesia.

CONCLUSIONS

General anesthesia and conscious sedation are both safe alternatives for anesthetic management of patients submitted to endovascular thrombectomy. No anesthetic management is universally recommended and hopefully the ongoing randomized clinical trials will shed some light on the best approach; meanwhile, the choice of anesthesia should be based on the patient's individual characteristics. Regarding neuroprotection, hemodynamic stability is currently the most important strategy, as no pharmacological method has been proven effective in humans.

Management of cardiac tamponade during catheter-directed thrombolysis of saddle pulmonary embolism: A clinical dilemma

Catheter-directed thrombolysis (CDT) for the treatment of acute pulmonary embolism (PE) has gained popularity in recent years, but potential complications during the procedure and their management are not frequently discussed in the literature. In this case report, we describe the clinical dilemma regarding the postoperative anticoagulation management of a 60-year-old male who developed cardiac perforation during a CDT of an acute saddle PE. Early resumption of systemic heparin in such cases may help in clot resolution; however, it can worsen the hemopericardium. On the other hand, delaying restarting heparin may help in healing of the cardiac perforation but can lead to clot propagation. As the chest tube output was minimal initially, anticoagulation was started, which, however, led to disastrous outcome. With limited published medical literature to help guide such a complex situation, it may be prudent to carefully weigh the risks and benefits of resuming systemic heparin versus delaying it for 1–2 days to allow for definitive resolution of the cardiac perforation.

Bailout rotational atherectomy in patients with myocardial infarction is not associated with an increased periprocedural complication rate or poorer angiographic outcomes in comparison to elective procedures (from the ORPKI Polish National Registry 2015-2016)

Introduction

Many years of experience and refinement of existing rotational atherectomy (RA) techniques have resulted in improved clinical outcomes and a tendency to broaden the spectrum of RA usage.

Aim

To compare the angiographic effectiveness and periprocedural complications in patients with stable angina (SA) and acute myocardial infarction (AMI) treated using RA.

Material and methods

Data were prospectively collected using the Polish Cardiovascular Intervention Society national registry (ORPKI) on all percutaneous coronary interventions (PCIs) performed in Poland in 2015 and 2016. In total, 975 RA procedures were recorded out of 221,187 PCI procedures.

Results

We compared angiographic effectiveness and periprocedural complications in 530 patients with SA and 245 with AMI in the RA group of patients, and 60,522 patients with SA and 91,985 with AMI in the non-RA group. The overall rate of periprocedural complications did not differ between SA and AMI patients in the RA group (2.3% vs. 2.0%; p = 0.84), while it was lower in AMI patients from the RA group compared to those from the non-RA group (2.0% vs. 3.0%; p = 0.34). The percentage of patients with angiographic success in the RA group was similar to the non-RA group in SA patients (97.3% vs. 97.1%; p = 0.75), whereas in the AMI group it was significantly higher compared to the non-RA group (96.7% vs. 92.6%; p < 0.001).

Conclusions

The angiographic effectiveness of PCI with RA in patients with AMI was not worse than in patients with SA.

Predictors of periprocedural complications in patients undergoing percutaneous coronary interventions within coronary artery bypass grafts

BACKGROUND

During the first decade following the coronary bypass grafting, at least ten percent of the patients require percutaneous coronary interventions (PCI) due to graft failure. Saphenous vein grafts (SVG) are innately at a higher risk of periprocedural complications. The present study aimed to investigate predictors of periprocedural complications of PCI within coronary artery bypass grafts.

METHODS

This study analyzed data gathered in the Polish National Registry (ORPKI) between January 2015 and December 2016. Of the 221,195 patients undergoing PCI, data on 2,616 patients after PCI of SVG and 442 patients after internal mammary artery (IMA) were extracted. The dissimilarities in periprocedural complications between the SVG, IMA and non-IMA/SVG groups and their predictors were investigated.

RESULTS

Patients in the SVG group were older (p < 0.001), with a higher burden of concomitant disease and differing clinical presentation. The rate of de-novo lesions was lower, while restenosis was higher at baseline in the SVG (p < 0.001). The rate of no-reflows (p < 0.001), perforations (p = 0.01) and all periprocedural complications (p < 0.01) was higher in the SVG group, while deaths were lower (p < 0.001). Among the predictors of no-reflows, it was found that acute coronary syndromes (ACS), thrombectomy and past cerebral stroke, while the complications included arterial hypertension, Thrombolysis in Myocardial Infarction (TIMI) flow before PCI and thrombectomy.

CONCLUSIONS

Percutaneous coronary interventions of SVG is associated with increased risk of specific periprocedural complications. The ACS, slower TIMI flow before PCI and thrombectomy significantly increase the periprocedural complication rate in patients undergoing PCI of SVG.

Clinical Outcomes of Polytetrafluoroethylene-Covered Stents for Coronary Artery Perforation in Elderly Patients Undergoing Percutaneous Coronary Interventions

Background

Coronary artery perforation (CAP) during percutaneous coronary intervention (PCI) is associated with increased mortality. Polytetrafluoroethylene covered stents (CS) are an effective approach to treat CAP, but data regarding elderly patients requiring CS implantation for CAP are limited. The aim of this study is to report clinical data for elderly CAP patients undergoing CS implantation during PCI.

Methods

Nineteen consecutive elderly patients (≥ 65 years) undergoing CS implantation due to PCI-induced CAP in a tertiary referral center from July 2003 to April 2016 were retrospectively examined.

Results

There were 13 men and six women, with a mean age of 75.3 ± 5.6 years (range: 65-86 years). Perforation grade was Ellis type II in five patients (26.3%), and Ellis type III in 14 patients (73.7%). Cardiac tamponade developed in six patients (31.6%), and intra-aortic balloon pumping was needed in four patients (21.1%). The overall success rate for CS implantation rate was 94.7%. The overall in-hospital mortality rate was 15.8%; the in-hospital myocardial infarction rate was 63.2%. Among 16 survival-to-discharge cases, dual antiplatelet therapy (DAPT) was prescribed in 14 cases (87.5%) for a mean duration of 14 months. Overall, there were five angiogram- proven CS failures among 18 patients receiving successful CS implantation. The 1, 2 and 4 years of actuarial freedom from the CS failure were 78%, 65%, and 43% in the angiogram follow-up patients.

Conclusions

CS implantation for CAP is feasible and effective in elderly patients, while CS failure remains a major concern that encourages regular angiographic follow-up in these case.

Incidence, Treatment, and Outcomes of Coronary Perforation During Chronic Total Occlusion Percutaneous Coronary Intervention

Coronary perforation is a potential complication of chronic total occlusion (CTO) percutaneous coronary intervention (PCI). We analyzed 2,097 CTO PCIs performed in 2,049 patients from 2012 to 2017. Patient age was 65 ± 10 years, 85% were men, and 36% had prior coronary artery bypass graft surgery. Technical and procedural success were 88% and 87%, respectively. A major periprocedural adverse cardiovascular event occurred in 2.6%. Coronary perforation occurred in 85 patients (4.1%); The frequency of Ellis class 1, 2, and 3 perforations was 21%, 26%, and 52%, respectively. Perforation occurred more frequently in older patients and those with previous coronary artery bypass graft surgery (61% vs 35%, p < 0.001). Cases with perforation were angiographically more complex (Multicenter CTO Registry in Japan score 3.0 ± 1.2 vs 2.5 ± 1.3, p < 0.001). Twelve patients (14%) with perforation experienced tamponade requiring pericardiocentesis. Patient age, previous PCI, right coronary artery target CTO, blunt or no stump, use of antegrade dissection re-entry, and the retrograde approach were associated with perforation. Adjusted odds ratio for periprocedural major periprocedural adverse cardiovascular events among patients with perforation was 15.04 (95% confidence interval 7.35 to 30.18). In conclusion, perforation occurs relatively infrequently in contemporary CTO PCI performed by experienced operators and is associated with baseline patient characteristics and angiographic complexity necessitating use of advanced crossing techniques. In most cases, perforations do not result in tamponade requiring pericardiocentesis, but they are associated with reduced technical and procedural success, higher periprocedural major adverse events, and reduced procedural efficiency.

Coronary Perforation Complicating Percutaneous Coronary Intervention in Patients With a History of Coronary Artery Bypass Surgery

Background—

The evidence base for coronary perforation (CP) occurring during percutaneous coronary intervention in patients with a history of coronary artery bypass surgery (PCI-CABG) is limited and the long-term effects unclear. Using a national PCI database, the incidence, predictors, and outcomes of CP during PCI-CABG were defined.

Methods and Results—

Data were analyzed on all PCI-CABG procedures performed in England and Wales between 2005 and 2013. Multivariate logistic regressions and propensity scores were used to identify predictors of CP and its association with outcomes. During the study period, 309 CPs were recorded during 59 644 PCI-CABG procedures with the incidence rising from 0.32% in 2005 to 0.68% in 2013 ( P <0.001 for trend). Independent associates of perforation in native vessels included age, chronic occlusive disease intervention, rotational atherectomy use, number of stents, hypertension, and female sex. In graft PCI, predictors of perforation were history of stroke, New York Heart Association class, and number of stents used. In-hospital clinical complications including Q-wave myocardial infarction (2.9% versus 0.2%; P <0.001), major bleeding (14.0% versus 0.9%; P <0.001), blood transfusion (3.7% versus 0.2%; P <0.001), and death (10.0% versus 1.1%; P <0.001) were more frequent in patients with CP. A continued excess mortality occurred after perforation, with an odds ratio for 12-month mortality of 1.35 for perforation survivors compared with matched nonperforation survivors without a CP ( P <0.0001).

Conclusions—

CP is an infrequent event during PCI-CABG but is closely associated with adverse clinical outcomes. A legacy effect of perforation on 12-month mortality was observed.

Prevalence and outcomes of coronary artery perforation during percutaneous coronary intervention

AIMS

We aimed to examine the prevalence, clinical outcomes and procedural characteristics of percutaneous coronary intervention (PCI) complicated by coronary artery perforation (CAP) in a contemporary patient population.

METHODS AND RESULTS

Procedural records of 39,115 patients undergoing PCI between 2005 and 2016 were reviewed. CAP affected 149 cases (0.37%). The prevalence of CAP increased from 0.31% in 2005 to 0.45% in 2016 (p=0.03), reflecting an increase in more complex PCI (from 14% in 2005 to 21% in 2016; p<0.0001). CAP was associated with increased all-cause mortality (23.1% vs. 9.4% in those without perforation; p=0.0054) and was an independent predictor of mortality (HR 2.55; 95% CI: 1.34-4.78). In-patient mortality was 4% (6/149). In 43 of 149 (28.9%) cases, a significant pericardial effusion ensued and mortality rates were higher in this subgroup. Thirty-one patients had covered stents (CS) inserted and five did not survive to discharge. Of the 26 patients with a CS who survived to hospital discharge, six (23.1%) had definite stent thrombosis, and two (7.7%) had possible/probable stent thrombosis.

CONCLUSIONS

CAP remains uncommon but the prevalence is increasing. CAP is associated with significant short- and long-term mortality, particularly when there is haemodynamic compromise necessitating pericardiocentesis. Covered stents are a valuable tool but they are associated with a high risk of stent thrombosis.

Legacy Effect of Coronary Perforation Complicating Percutaneous Coronary Intervention for Chronic Total Occlusive Disease

Background—

Coronary perforation (CP) during chronic total occlusion percutaneous coronary intervention for stable angina (CTO-PCI) is a rare but serious event. The evidence base is limited, and the long-term effects are unclear. Using a national PCI database, the incidence, predictors, and outcomes of CP during CTO-PCI were defined.

Methods and Results—

Data analyzed from the British Cardiovascular Intervention Society data set on all CTO-PCI procedures performed in England and Wales between 2006 and 2013. Multivariate logistic regressions and propensity scores were used to identify predictors of CP and its association with outcomes. A total of 376 CP were recorded from 26 807 CTO-PCI interventions (incidence of 1.40%) with an increase in frequency during the study period ( P =0.012). Patient-related factors associated with an increased risk of CP were age and female sex. Procedural factors indicative of complex CTO intervention strongly related to an increased risk of CP with a close relationship between the number of complex strategies used and CP evident ( P =0.008 for trend). Tamponade occurred in 16.6% and emergency surgery in 3.4% of cases. Adverse outcomes were frequent in those patients with perforation including bleeding, transfusion, myocardial infarction, and death. A legacy effect of perforation on mortality was evident, with an odds ratio for 12-month mortality of 1.60 for perforation survivors compared with matched nonperforation survivors without a CP ( P <0.0001).

Conclusions—

Many of the factors associated with an increased risk of CP were related to CTO complexity. Perforation was associated with adverse outcomes, with a legacy effect on later mortality after CP also observed.

Comparison of Characteristics and Complications in Men Versus Women Undergoing Chronic Total Occlusion Percutaneous Intervention

Gender differences exist in clinical outcomes after routine percutaneous coronary intervention (PCI), but studies reporting such outcomes after chronic total occlusion (CTO) PCI are limited. We assessed the characteristics and outcomes of female patients undergoing CTO PCI. We retrospectively analyzed a dedicated national (United Kingdom) prospective CTO database from 2011 to 2015 for outcomes and characteristics of female patients undergoing CTO PCI (unmatched and propensity matched). Female patients constituted 20.5% (n = 260 of 1,271) of the unmatched cohort and 33.3% (n = 233 of 699) of the matched cohort and were more likely to be older (women aged >70 years, 48% in the unmatched and 45% in the matched cohort). An increased inhospital complication rate was observed in female patients (unmatched: 10% women vs 4.45% men, p = 0.0012, and matched 9.87% women vs 3.86% men, p = 0.0032). Coronary perforation, bleeding, and contrast-induced nephropathy were more frequently observed in female patients. Femoral access site with >6 French sheath was associated with an increased risk of bleeding. Presence of calcification in the CTO artery was associated with coronary perforation (grade III) in female patients in the matched cohort (p = 0.007). Female patients undergoing CTO PCI were older and experienced increased of inhospital complications. Increased awareness of these complications could influence the selection of access site and sheath size, the need for prehydration, judicious choice of balloon size, collateral selection, and wire placement in female patients undergoing CTO PCI.