Coronary artery perforation during percutaneous coronary intervention: a systematic review and meta-analysis

Numerous studies have examined the incidence, predictors, outcomes, and management strategies of coronary artery perforation (CAP). Individually, these studies have been inconclusive because of their limited sample sizes and/or single-centre designs. We conducted a systematic review and meta-analysis of studies pertaining to CAP in order to estimate its incidence and outcomes and to critically review its risk factors and treatment. We systematically searched the literature to identify all registry studies investigating CAP. Data were pooled by means of the random-effects model. In 16 studies involving 197,061 percutaneous coronary interventions, the pooled incidence of CAP was 0.43% (95% confidence interval, 0.35%-0.52%). The most reproducible risk factors were treatment of complex lesions and use of atheroablative devices. A variety of major management strategies for CAP were used, in particular, observation, heparin reversal, prolonged balloon inflation, covered stent implantation, pericardiocentesis, and surgery. In a hierarchical Bayesian random-effects model, the pooled tamponade rates were 0.4% (95% credible interval [CrI], 0.0%-5.7%), 3.3% (95% CrI, 0.0%-11.4%), and 45.7% (95% CrI, 34.9%-57.5%) for patients with Ellis class I, II, and III CAP, respectively. Pooled mortality rates were 0.3% (95% CrI, 0.0%-4.4%), 0.4% (95% CrI, 0.0%-2.8%), and 21.2% (95% CrI, 12.0%-31.4%) for patients with Ellis class I, II, and III CAP respectively. CAP complicating percutaneous coronary intervention is rare, and its morbidity and mortality vary directly with Ellis classification. Management discrepancies highlight the need to establish a uniform treatment paradigm for CAP.