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Published on: February 18, 2020
The changing pattern of coronary perforation during percutaneous coronary intervention in the new device era
Christian F Witzke1, Francisco Martin-Herrero, Sarah C Clarke
1Cardiac Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 02114, USA.
Insights
Coronary perforations during percutaneous coronary intervention (PCI) are rare (0.3%), often caused by guidewire injury, and more frequent with debulking devices. Management involves early detection and vessel occlusion, with favorable outcomes despite complications like pericardial effusion.
Area of Science:
- Interventional Cardiology
- Vascular Medicine
Background:
- Percutaneous coronary intervention (PCI) is a common procedure for treating coronary artery disease.
- Coronary artery perforation is a rare but serious complication of PCI.
Purpose of the Study:
- To report the incidence, management, and clinical outcomes of coronary perforations during PCI.
- To identify risk factors and effective treatment strategies for coronary perforations.
Main Methods:
- Retrospective analysis of 12,658 patients undergoing PCI.
- Classification of perforations into Type I, II, and III.
- Review of management strategies and clinical outcomes.
Main Results:
- Coronary perforation incidence was 0.3% (39 patients).
- Debulking techniques had higher perforation rates (1%) than non-debulking (0.2%).
- Guidewire manipulation caused 51% of perforations; Type III had worse outcomes.
- Pericardial effusion occurred in 46.2%, cardiac tamponade in 7 patients.
- Mortality was 2.6%, with no Q-wave myocardial infarctions.
Conclusions:
- Coronary perforation incidence remains low in the current device era.
- Debulking devices and guidewire manipulation are associated with increased perforation risk.
- Prompt detection, classification, and management are crucial for favorable outcomes.
Abstract:
We report the incidence, management and clinical outcome of coronary perforations in 39 of 12,658 patients (0.3%) undergoing percutaneous coronary intervention (PCI). Coronary perforation occurred more frequently with debulking techniques than with non-debulking (percutaneous transluminal coronary angioplasty and stent) techniques (1% versus 0.2%; p<0.001). There were 8 type I (20.5%), 15 type II (38.5%) and 16 type III (41%) perforations. Importantly, fifty-one percent of the coronary perforations were guide-wire related. Major adverse clinical outcomes occurred more frequently in patients who experienced type III perforations. Conventional strategies to treat perforations (i.e., prolonged balloon inflation and reverse of the anticoagulated state) were used. There was one death (2.6%), two emergency surgeries (5.2%) and no Q-wave myocardial infarctions. Pericardial effusion occurred in 18 of 39 patients (46.2%), with cardiac tamponade occurring in 7 patients. In the current device era, the incidence of coronary perforation remains low; it occurs more frequently with debulking devices and is often a consequence of guidewire injury. Its outcome is not affected with the use of IIb/IIIa antagonists. Treatment of coronary perforation requires early detection, angiographic classification, immediate occlusion of coronary vessel extravasation and relief of hemodynamic compromise, reversal of heparin anticoagulation, platelet transfusion in those patients treated with abciximab and cover stents.
