Coronary perforations and its clinical impact during CTO recanalization: a 2054 patients pooled analysis from the Latin American (LATAM) CTO registry

Introduction

Percutaneous coronary intervention (PCI) of chronic total occlusions (CTO) are the most challenging procedures and still associated with the highest complications rates. Coronary perforation is a life-threatening acute PCI complication, but data are limited regarding its impact on mid-term outcome. We aimed to assess 30-days and 1-year outcomes in CTO PCI patients with coronary perforations.

Purpose

Analyze the clinical impact of Cto perforations during CTO PCI at short and mid-term in a muticenter continental registry in Latin America (LATAM).

Methods

We analyzed data from the continental multicenter Latin America CTO Registry including patients who underwent CTO PCI in 57 centers from 9 countries. Coronary perforation during the index procedure were categorized according to Ellis classification. We assessed 30-days adverse events and 1-year major adverse cardiac and cerebrovascular (MACCE) defined as the composite of all-cause death, myocardial infarction (MI), target vessel revascularization and stroke. MI was defined according both the LATAM CTO protocol and SCAI definitions.

Results

From January 2015 to October 2018, 2054 patients underwent CTO PCI. The median J-CTO score was 2.0 (1.0–3.0) and the median Progress score was 1.0 (0.0–2.0). The overall perforation rate was 3.7% (n=76) in which 55% were Ellis class 1, 24% Ellis class 2 and 21% Ellis class 3. No differences were found in any baseline clinical characteristics. Patients with perforation had more frequently retrograde instrumentation (P<0.01) and antegrade knuckle wire (P<0.01) and lower success rate (P<0.01). At 30-days, perforations were associated with more heart failure (6.6% vs 1.5%, p<0.01), bleeding (15.2% vs 3.7%, p<0.01), transfusion (7.9% vs 1.1%, p<0.01) and cardiac tamponade (13.2% vs 0.4%, p<0.01). After 1-year follow-up, patients with perforations had higher MACCE rates according to both LATAM CTO protocol (18.2 vs. 9.4%; P=0.02) and SCAI definitions (22.7% vs. 11.3%; P<0.01).

Conclusions

In this multicenter continental real-world analysis, coronary perforation in CTO PCI was infrequent and was related with higher anatomical and procedural complexity characteristics. Despite the similarity in clinical characteristics, patients that had coronary perforation were exposed to an increased risk of both hemorrhagic and ischemic events.

Funding Acknowledgement

Type of funding sources: None.

P4598Clinical implications and predictors of coronary perforations during chronic total occlusion percutaneous coronary interventions: insights from the multicenterLatin America CTO LATAM registry

Background

Chronic total occlusions are still considered one of the most challenging procedures in the field of interventional cardiology and the most feared complication are the perforations. In past studies and series from Asia, Europe and United States the rate of perforations in percutaneous coronary interventions are described as 0.2% whereas this rate increases to 3% when recanalization of a chronic total occlusion is attempted.

Purpose

Our study sought to identify the frequency, predictors and clinical implications of coronary perforations in chronic total occlusion percutaneous interventions in a contemporary registry with data from Latin America.

Methods

We reported the data of a prospective multi center Latin American registry from January to December 2018 in 1066 patients who underwent chronic total occlusion percutaneous interventions in 30 centers in the following countries: Brazil, Argentina, Puerto Rico, Chile, Colombia, Ecuador and Mexico. Coronary perforation was defined as evidence of extravasation dye or blood from the coronary artery during or following the procedure. A stepwise logistic regression was performed to investigate the independent predictors of coronary perforations.

Results

The mean age was 64.2±10.7 years, 79.8% were male, 35.3% diabetics and 6.7% had heart failure. The most commonly involved CTO vessel was right coronary artery (41.4%), the mean J-CTO score was 2.0±1.3 and the mean CL score was 2.7±1.6. The overall procedural success rate was 81.9%. Coronary perforation occurred in 3.3% of cases: type 1 in 1.8%, Type 2 in 0.9% and Type 3 in 0.6%. In comparison with patients without coronary perforation was observed, those with such complication required more often blood transfusion (8.6% vs. 0.7%; p<0.001), experienced more cardiac tamponade (13.4% vs. 0.4%; p<0.001), but not all-cause in-hospital mortality (0 vs. 1.0%; p=1.0; respectively). At multivariate analysis, the independent predictor of coronary perforation was an activated clotting time (ACT) during PCI >470 seconds (OR 6.5; 95% CI 2.4 - 17.3; p<0.001), baseline heart failure (OR 4.2; 95% CI 1.2 - 14.6) and J-CTO score ≥2 (OR7.5; 95% CI 1.0–59.1).

Conclusions

Coronary perforation during percutaneous interventions in Latin America occurred in 3.3% of patients, being related with adverse events but not in-hospital all-cause mortality. Pharmacological management, high anatomical complexity and heart failure were identified as independent predictors of this still and so feared complication.

Acknowledgement/Funding

None