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

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.

Imaging Features of Complications after Coronary Interventions and Surgical Procedures

Coronary artery interventions and surgical procedures are used in the treatment of coronary artery disease and some congenital heart diseases. Cardiac and noncardiac complications can occur at variable times after these procedures, with the clinical presentation ranging from asymptomatic to devastating symptoms. Invasive coronary angiography is the reference standard modality used in the evaluation of coronary arteries, with intravascular US and optical coherence tomography providing high-resolution information regarding the vessel wall. CT is the mostly commonly used noninvasive imaging modality in the evaluation of coronary artery intervention complications and allows assessment of the stent, lumen of the stent, lumen of the coronary arteries, and extracoronary structures. MRI is limited to the evaluation of the proximal coronary arteries but allows comprehensive evaluation of the myocardium, including ischemia and infarction. The authors review the clinical symptoms and pathophysiologic and imaging features of various complications of coronary artery interventions and surgical procedures. Complications of percutaneous coronary interventions are discussed, including restenosis, thrombosis, dissection of coronary arteries or the aorta, coronary wall rupture or perforation, stent deployment failure, stent fracture, stent infection, stent migration or embolism, and reperfusion injury. Complications of several surgical procedures are reviewed, including coronary artery bypass grafting, coronary artery reimplantation procedure (for anomalous origin from opposite sinuses or the pulmonary artery or as part of surgical procedures such as arterial switching surgery and the Bentall and Cabrol procedures), coronary artery unroofing, and the Takeuchi procedure. Online supplemental material is available for this article. ^©RSNA, 2021.

Viabahn stent graft in the management of a grade 3 coronary perforation

Background

Coronary artery perforation during coronary intervention has high morbidity and mortality. This case describes the collaboration between interventional cardiologists and Interventional radiologists to successfully deploy a peripheral arterial stent graft in a coronary artery that demonstrated persistent extravasation after coronary specific stent graft placement.

Case presentation

An 84 year old female patient presented with acute coronary syndrome and coronary angiography identified a right coronary artery lesion. This was dilated and stented but resulted in a grade 3 coronary perforation. Conservative treatment with balloon tamponade failed, as did placement of a covered coronary-specific stent graft. A Viabahn peripheral arterial stent graft was placed within the indwelling stents and successfully sealed the endoleak. At 6 months the patient is clinically well and follow-up imaging has demonstrated stent patency.

Conclusions

In the emergency setting when coronary artery perforation fails to respond to standard initial and bail out techniques, peripheral arterial techniques and devices can be extremely useful. A good relationship between interventional cardiology and radiology is paramount.

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.

The predictors of complications in balloon pulmonary angioplasty for chronic thromboembolic pulmonary hypertension

OBJECTIVES

The aims of this study were to (1) evaluate risk factors of complications of balloon pulmonary angioplasty (BPA) and (2) assess the mechanism of the complications.

BACKGROUND

BPA represents a promising treatment option in patients with inoperable chronic thromboembolic pulmonary hypertension (CTEPH). However, the complication ratio differs across reports, and the causes remain controversial.

METHODS

All complications found by angiography and non-contrasted computerized tomography (CT) immediately after BPA were recorded. New emergences of a ground-glass pattern or consolidation in CT after BPA that were not recognized on CT images before BPA were counted as pulmonary bleeding. Lesion morphologies were classified into four types (web, ring, abrupt narrowing and occlusive lesions) according to selective pulmonary angiography.

RESULTS

Thirty patients consented to analysis of the BPA-related images, and 879 lesions (112 sessions) were evaluated. One hundred and twenty-two (99.2%) of 123 complications were confirmed to be associated with BPA procedures at the local area. In the multivariate analysis, occlusive lesions were the sole independent predictor of procedure-related complications (adjusted odds ratio 5.83, 95%CI [1.94-17.47], p = 0.002). Hemodynamic parameters were not predictors of complications. CT images after BPA presented the predictive value for the occurrence of hemoptysis.

CONCLUSIONS

Almost all complications were attributed to operators' procedures. Lesion morphology was the sole predictor of BPA-related complications, while hemodynamic parameters were not associated with the frequency of complications. CT scan images after BPA were useful to identify bleeding complications and to predict hemoptysis.

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.

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.

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.

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.

Short-Term and Long-Term Outcomes After Polytetrafluoroethylene-Covered Stent Implantation for the Treatment of Coronary Perforation

This study sought to evaluate the short-term and 3-year outcomes of polytetrafluoroethylene-covered stent (PCS) for patients with coronary perforation. Implantation of a PCS has improved the immediate clinical outcomes of patients with coronary perforation. However, there are few reports regarding long-term outcomes. We evaluated a total of 57 patients who were treated with PCS for coronary perforation from April 2004 to March 2015 at a single high-volume center in Japan. Landmark analysis was performed at 30 days to determine short-term and long-term outcomes. Major adverse cardiac events (MACE) were defined as death, myocardial infarction, target vessel revascularization, and requirement for surgical repair. Of 285 patients who experienced coronary perforation, 57 patients (20%) were treated with PCS. The MACE rates were 28% at 30 days, 22% at 1 year, and 38% at 3 years. 30-day MACE was mainly driven by high rates of myocardial infarction (18%) and surgical repair (16%). The rates of target lesion revascularization were 8% and 12% at 1 and 3 years, respectively. Definite stent thrombosis was reported in 2 patients during the follow-up period. In conclusion, despite the relatively high incidence of MACE during early stage of follow-up, implantation of a PCS provides acceptable late clinical outcomes.

Treatment of right ventricular perforation during percutaneous coronary intervention

Percutaneous coronary intervention (PCI) is widely used to treat stenotic coronary arteries caused by coronary heart disease. Coronary artery perforation is a rare but dreaded complication of PCI. Here, we report the successful treatment of a patient with coronary perforation of the right ventricular cavity. To our knowledge, this is the first report of its kind. The patient was a 69-year-old woman with intermittent chest tightness and chest pain of about five years' duration who was hospitalised for severe chest tightness and pain persisting for three days. She had a history of hypertension and hyperlipidaemia; routine admission examination showed no other abnormalities. Results of routine blood, urine and stool tests, liver and kidney function, clotting time, electrocardiogram, chest radiography and echocardiography were normal. Although coil embolisation rather than balloon is safe and effective for treating coronary artery perforation, it may be not the best choice overall. If the perforation breaks through into the right ventricle, we may just monitor closely rather than treat. That course may be beneficial for patients in that it reduces the risk of myocardial cell necrosis. This case provides useful information for the treatment of such patients in the future.

Coronary Perforation Complicating Percutaneous Coronary Intervention - A Case Illustration and Review

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.

Successful management of coronary artery rupture with stent-graft: a case report

Perforation of coronary arteries is a relatively rare yet life-threatening complication of percutaneus coronary interventions and is encountered in approximately 0.5% of these procedures. According to the type of coronary perforation, various methods of correction are employed, ranging from conservative approach to emergency cardiac surgery. Coronary stent-grafts are composed of two metal stents and a polytetrafluoroethylene layer between them. Advent of such stents enabled efficient endovascular repair of coronary artery perforation. We present a case of coronary artery perforation which had occurred during stent implantation for the treatment of a bridged segment in the distal portion of the left anterior descending artery. This perforation was successfully managed by implanting a stent-graft.

Coronary Artery Perforation following PCI: An Interesting Finding into the Pericardial Space

Coronary artery perforation is a known complication of percutaneous coronary intervention and potentially life threatening. Normally, these perforations are small and localized. We report the successful surgical management of a coronary artery perforation following stent insertion with extrusion of an 8-cm endarterectomy length of the circumflex coronary artery with a brief review of the recent literature.

Coronary artery perforations: four different cases and a review

Coronary artery perforation (CAP) is a rare but feared complication of percutaneous coronary intervention. With the advent of new devices and technologies, interventionalists attempt more complex lesions, including more calcified or tortuous vessels and chronic total occlusions, which increases the incidence of CAP. A short literature review, in addition to four cases of CAP, is presented in this report.

Outcome of prolonged balloon inflation for the management of coronary perforation

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.

Coronary perforation and covered stents: an update and review

Coronary perforation is a rare complication of percutaneous coronary intervention. We present two different types of coronary intervention, but both ending with coronary perforation. However, these perforations were tackled successfully by covered stents. This article reviews the incidence, causes, presentation, and management of coronary perforation in the present era of aggressive interventional cardiology. Coronary perforations are classified as type I (extraluminal crater), II (myocardial or pericardial blushing), and III (contrast streaming or cavity spilling). Types I and II coronary perforations are caused by stiff or hydrophilic guidewires. Type I has a benign prognosis, whereas type II coronary perforations have the potential to progress to tamponade. Type III coronary perforations are caused by balloons, stents, or other intracoronary devices and commonly lead to cardiac tamponade necessitating pericardial drainage. However, type III perforations can be managed with covered stents without need for surgical intervention.

Fatal delayed coronary artery perforation after coronary stent implantation

Most type I and II perforations are predominately caused by hydrophilic and stiff wires, often presented in the delayed form, and do not require pericardial drainage or surgical interventions. However, we report a type III delayed coronary artery perforation at the site of stent implantation after intervention without any evidence of immediate perforations. To the best of our knowledge, this is the first case report of angiographic documentation and treatment of delayed coronary perforation at the site of stent, presented as a cardiac arrest.

Successful surgical management of coronary perforation requiring pulmonary artery separation

A 73-year-old woman with type III coronary perforation caused by failed angioplasty underwent emergency operation. It was impossible to stop the bleeding from the beating heart because the proximal Cx, which was the perforation site, was behind the main pulmonary artery. After establishing cardiopulmonary bypass, we separated the main pulmonary artery to secure hemostasis and performed coronary artery bypass grafting to the distal Cx. The postoperative course was uneventful therefore the patient was discharged on the tenth postoperative day. Surgical strategies are not standardized for coronary perforation and depend mainly on the surgical anatomy. In a situation like the present, which appears not to have been described previously, it is important to save the life of the patient by whatever means.

Surgical treatment for Ellis type 3 coronary perforation during percutaneous catheter intervention

BACKGROUND

Coronary perforation (CP) is a rare, but sometimes lethal, complication of percutaneous catheter intervention (PCI). We reviewed surgically-treated cases of type 3 CP during PCI.

METHODS AND RESULTS

From 2007 to 2010, 5 patients underwent surgical repair for type 3 CP (3 men, 2 women; mean age, 74 years). The mean number of diseased coronary branches was 2.6 and the mean SYNTAX score was 45. The target lesions were the left anterior descending artery in 4 cases and the right coronary artery in 1 case. Types of American Heart Association/American College of Cardiology classification were type B2 in only one case and type C in 4 cases. The causes of perforation were balloon inflation in 4 patients and rotational atherectomy in 1 patient. The in-hospital mortality rate was 20%. In the cases of CP associated with balloon inflation, coronary lacerations were so severe that re-bleeding occurred even if the covered stent could temporarily achieve hemostasis, and percutaneous cardiopulmonary support and emergency surgery were required.

CONCLUSIONS

CP induced by balloon inflation tends to result in a serious condition compared with rotablator-induced CP. Surgery should be immediately performed even after covered stent implantation if there is any possibility of re-bleeding in the case of balloon-induced type 3 CP.

Is a metallic microcoil really a permanent embolic agent for the management of distal guidewire-induced coronary artery perforation?

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.

Incidence, predictors, management, immediate and long-term outcomes following grade III coronary perforation

OBJECTIVES

The aim of this study was to evaluate the incidence, predictors, management, and clinical outcomes in patients with grade III coronary perforation during percutaneous coronary intervention.

BACKGROUND

Grade III coronary perforation is a rare but recognized complication associated with high morbidity and mortality.

METHODS

From 24,465 patients undergoing percutaneous coronary intervention from May 1993 to December 2009, 56 patients had grade III coronary perforation.

RESULTS

Most lesions were complex: 44.6% type B2, 51.8% type C, and 28.6% chronic total occlusions, and within a small vessel (≤ 2.5 mm) in 32.1%. Glycoprotein IIb/IIIa inhibitors were administered in 17.9% of patients. The device causing perforation was intracoronary balloon in 50%: 53.6% compliant, 46.4% noncompliant; intracoronary guidewire in 17.9%; rotablation in 3.6%; and directional atherectomy in 3.6%. Following perforation, immediate treatment and success rates, respectively, were prolonged balloon inflation 58.9%, 54.5%; covered stent implantation 46.4%, 84.6%; coronary artery bypass graft surgery (CABG) and surgical repair 16.0%, 44.4%; and coil embolization 1.8%, 100%. Multiple methods were required in 39.3%. During the procedure (n = 56), 19.6% required cardiopulmonary resuscitation and 3.6% died. In-hospital (n = 54), 3.7% required CABG, 14.8% died. The combined procedural and in-hospital myocardial infarction rate was 42.9%, and major adverse cardiac event rate was 55.4%. At clinical follow-up (n = 46) (median: 38.1 months, range 7.6 to 122.8), 4.3% had a myocardial infarction, 4.3% required CABG, and 15.2% died. The target lesion revascularization rate was 13%, with target vessel revascularization in 19.6%, and major adverse cardiac events in 41.3%.

CONCLUSIONS

Grade III coronary perforation is associated with complex lesions and high acute and long-term major adverse cardiac event rates.

Coronary artery perforation by intracoronary guide wires: risk factors and clinical outcomes

The aims of this study were to determine the incidence of coronary artery perforation by intracoronary guide wires during angioplasty, to identify associated factors, and to assess outcomes. The retrospective analysis covered 4,353 consecutive procedures, corresponding to a total 6,994 lesions treated over a period of 8 years. Coronary artery perforation by guide wires occurred in 15 cases (0.35%). Perforation was associated with the number of hydrophilic wires used (odds ratio=2.33; 95% confidence interval, 1.34-4.05) and treatment of chronic occlusions (odds ratio=3.31; 95% confidence interval, 1.05-10.46). Cardiac tamponade occurred in seven cases (46.7%), six of which were subacute. Three cases were resolved by pericardiocentesis, while four required surgical drainage. Cardiac tamponade was associated with the number of guide wires used (P=.039) and the use of abciximab (P=.016). No death occurred.

Incidence, risk factors, management and outcomes of coronary artery perforation during percutaneous coronary intervention

Coronary artery perforation (CP) is a rare, sometimes lethal complication of percutaneous coronary intervention. There are limited controlled contemporary data regarding its predictors, incidence, and outcomes. The aim of this study was to define the incidence, associated factors, and outcomes of CP in the current era of coronary intervention. All patients who had CP during percutaneous coronary intervention at a large tertiary center from January 2001 to December 2008 were identified. Demographic, clinical, and procedural data and outcome variables were obtained. Patients with CP were compared with a randomly assigned control group. Fifty-seven patients with CP were identified among 9,568 interventions performed during the study period (0.59%); these patients were compared with 171 who underwent percutaneous coronary intervention without CP. Vessels were perforated by wires (52.6%), balloons (26.3%), and stents (21.1%). Perforations were classified using the Ellis classification. CP was associated with mortality and tamponade rates of 7% and 16%, respectively, but all these serious complications occurred with grade III perforations. Most grade I and II perforations were managed conservatively. Multivariate analysis identified the treatment of chronic total occlusion as the strongest independent predictor of CP; other independent variables included calcium in the coronary artery that was the site of intervention and non-ST elevation myocardial infarction.

Outcomes of patients with coronary artery perforation complicating percutaneous coronary intervention and correlations with the type of adjunctive antithrombotic therapy: pooled analysis from REPLACE-2, ACUITY, and HORIZONS-AMI trials

BACKGROUND

The lack of a specific counteragent to bivalirudin may complicate the management of patients with coronary artery (CA) perforation during percutaneous coronary intervention (PCI).

AIM

Assess outcomes of patients with CA perforation from three PCI trials comparing intravenous bivalirudin with provisional glycoprotein (GP) IIb/IIIa inhibition versus unfractionated heparin (UFH) plus GP IIb/IIIa.

METHODS

A pooled analysis of patients treated with PCI in three randomized trials including REPLACE-2, ACUITY, and HORIZONS-AMI.

RESULTS

Among a total of 12,921 patients, CA perforation occurred in 35 patients (0.27%). By multivariable analysis, baseline creatinine clearance was the only independent predictor of CA perforation (per 10 mL/min decrease, odds ratio [95% confidence interval]= 1.28 [1.11, 1.47], P = 0.0007). At 30 days, patients with versus without CA perforation had significantly (all P values < or =0.001) higher rates of 30-day mortality (11.4% vs. 1.0%), myocardial infarction (MI) [Q wave: 22.9% vs. 5.7%; non-Q wave: 17.1% vs. 4.9%], target vessel revascularization (TVR) [20.1% vs. 1.8%], and composite end-point of death/MI/TVR (31.4% vs. 7.8%). Patients assigned to bivalirudin versus UFH plus a GP IIb/IIIa inhibitor had nonsignificantly lower rates of death (0% vs. 18.8%, P = 0.08), similar rates of MI (26.7% vs. 25.0%, P = 0.92), significantly lower rates of TVR (6.7% vs. 37.5%, P = 0.04), and similar rates of the composite end-point of death/MI/TVR (35.5% vs. 26.7%, P = 0.54).

CONCLUSION

In three PCI trials, treatment of patients experiencing CA perforation with adjunctive antithrombotic therapy of bivalirudin monotherapy was not associated with worse outcomes compared to treatment with UFH plus GP IIb/IIIa inhibitors.

Pseudoaneurysm with thrombus and left ventricular inflow obstruction after left circumflex stenting

A 61-year-old woman had stenting of the left circumflex coronary artery. She had a repeat coronary angiogram the day after stenting because of hypotension and orthopnea. The left circumflex stent was patent. A transesophageal echocardiogram showed a 2.5 cm x 3.0-cm mass in the atrioventricular groove compressing the left atrium. A pseudoaneurysm with thrombus and left ventricular inflow obstruction was diagnosed. The patient was observed for 48 hours to allow the pseudoaneurysm to seal and coagulate. She then had surgical evacuation of the thrombus, which had caused her hypotension and orthopnea by compression of the left atrium.

Use of stent grafts and coils in vessel rupture and perforation

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

Magnetically-assisted remote control (MARC) steering of endovascular catheters for interventional MRI: a model for deflection and design implications

Current applied to wire coils wound at the tip of an endovascular catheter can be used to remotely steer a catheter under magnetic resonance imaging guidance. In this study, we derive and validate an equation that characterizes the relationship between deflection and a number of physical factors: theta/sin(gamma-theta) = nIABL/EI(A) where theta is the deflection angle, n is the number of solenoidal turns, I is the current, A is the cross-sectional area of the catheter tip, B is the magnetic resonance (MR) scanner main magnetic field, L is the unconstrained catheter length, E is Young's Modulus for the catheter material, and I(A) is the area moment of inertia, and y is the initial angle between the catheter tip and B. Solenoids of 50, 100, or 150 turns were wound on 1.8 F and 5 F catheters. Varying currents were applied remotely using a DC power supply in the MRI control room. The distal catheter tip was suspended within a phantom at varying lengths. Images were obtained with a 1.5 T or a 3 T MR scanner using "real-time" MR pulse sequences. Deflection angles were measured on acquired images. Catheter bending stiffess was determined using a tensile testing apparatus and a stereomicroscope. Predicted relationships between deflection and various physical factors were observed (R2 = 0.98-0.99). The derived equation provides a framework for modeling of the behavior of the specialized catheter tip. Each physical factor studied has implications for catheter design and device implementation.

The Straight Wire Sign: Recognizing guidwire exit during percutaneous coronary intervention for chronic total occlusion

Coronary perforation during PCI may be life threatening. Use of stiff wires during instrumentation of totally occluded arteries is a contributing factor. The "Straight Wire" sign presented here was realized from a case of coronary perforation encountered at our cath lab. The identification of this sign in another patient prompted immediate response and avoided further complications.

Coronary perforation during percutaneous coronary intervention

Coronary perforation is an undesirable complication during percutaneous coronary intervention (PCI). We reviewed the cases of overt coronary perforation in our institute and analyzed their clinical backgrounds, the characteristics of the target lesion, management, and clinical outcomes. Between 1991 and 2005, we experienced 12 cases (0.35%) of coronary perforation in a total of 3415 PCI procedures. The perforation occurred during the use of debulking devices in 3 cases, immediately after stenting in 2, immediately after postdilatation of the stent in 2, and during wiring in 3 cases. Restoration was attempted by long inflation of a balloon in 7 cases, implantation of a covered stent graft in 1, and emergency surgical repair in 1 case. Subsequent cardiac tamponade occurred in 3 patients who required pericardiocentesis, and 1 patient died due to congestive heart failure. Administration of protamine was effective in stopping the bleeding in 6 patients, whereas continuation of antiplatelet therapy resulted in no overt rebleeding. Coronary perforation during PCI is a rare complication but is associated with significant morbidity and mortality. Intravenous administration of protamine is effective when it is used in conjunction with nonsurgical devices for initial management of perforation.