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Coronary artery perforation during percutaneous intervention: incidence and outcome
M G Gunning1, I L Williams, D E Jewitt
1Department of Cardiology, Kings College Hospital, London, UK. gunningmark@hotmail.com
Insights
Coronary artery perforation during percutaneous coronary intervention is rare but serious. Pericardial tamponade has high mortality, but covered stents offer a rescue option, while abciximab use requires caution.
Area of Science:
- Cardiology
- Interventional Cardiology
- Vascular Surgery
Background:
- Percutaneous coronary intervention (PCI) is a common procedure for treating coronary artery disease.
- Vessel perforation is a rare but potentially life-threatening complication of PCI.
- Understanding the outcomes and management strategies for PCI-related vessel perforation is crucial.
Purpose of the Study:
- To evaluate the clinical outcomes of patients undergoing PCI complicated by vessel perforation.
- To identify risk factors and management strategies for PCI-induced coronary artery perforation.
- To assess the efficacy of different treatment modalities, including conservative management, surgery, and covered stents.
Main Methods:
- Retrospective review of procedural records from a tertiary referral center.
- Analysis of 6245 patients undergoing coronary intervention, with a focus on 52 cases (0.8%) complicated by vessel perforation.
- Classification of perforation severity and documentation of management strategies and patient outcomes.
Main Results:
- Vessel perforation occurred in 0.8% of PCI procedures, with 46% resulting in significant pericardial effusion requiring drainage.
- Among patients with effusion, 33% required emergency bypass surgery, and 33% of those died.
- Pericardial tamponade was frequent (90%) when abciximab was administered, and covered stents were successfully used in two cases.
Conclusions:
- Coronary artery perforation during PCI is infrequent (0.4% with sequelae) but associated with significant morbidity and mortality, especially in complex lesions like chronic occlusions.
- Pericardial tamponade carries a high mortality rate, underscoring the need for prompt intervention.
- Covered stents represent a promising rescue therapy, and caution is advised when using abciximab in cases of perforation.
Objective:
To examine the clinical outcome of percutaneous coronary intervention where the procedure was complicated by vessel perforation.
Setting:
Tertiary referral centre.
Methods:
The procedural records of 6245 patients undergoing coronary intervention were reviewed. In 52 patients (0.8%) the procedure was complicated by vessel perforation, ranging from wire exit to free flow of contrast into the pericardial space. The majority of lesions treated were complex (37% type B, 59% type C) and 9 of 52 (17%) were chronic occlusions. Ten patients (19%) received abciximab. Four underwent rotational atherectomy (8%).
Results:
In 28 of 52 patients (54%) the perforation was benign and managed conservatively without the development of haemodynamically significant sequelae. In 24 of 52 (46%) a significant pericardial effusion ensued requiring drainage. Of these 24 procedures 6 had involved the treatment of a chronic occlusion (25%). Eight of the 24 patients were referred for emergency bypass surgery (33%), 3 of whom died. Of the remaining 16 not referred for surgery, 3 died. Of the 10 procedures complicated by vessel perforation where abciximab had been administered, 9 (90%) led to pericardial tamponade. Latterly 2 vessel perforations were successfully treated by the deployment of a covered stent.
Conclusions:
Coronary artery perforation with sequelae during intervention is rare--26 of 6245 (0.4%). This complication was seen in the treatment of chronic occlusions, which are therefore not risk-free procedures. The development of pericardial tamponade carries a high mortality. While prompt surgical intervention may be life saving, expertise in the use of covered stents may provide a valuable rescue option for this serious complication. Caution should be exercised where coronary perforation occurs and abciximab has been used.