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Coronary artery perforation during chronic total occlusion percutaneous coronary intervention: epidemiology,
Lorenzo Azzalini1, Enrico Poletti, Mohamed Ayoub
1Interventional Cardiology Division, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy.
Insights
Coronary artery perforation occurs in 5.5% of chronic total occlusion (CTO) percutaneous coronary interventions (PCI), often needing intervention and increasing mortality risk. CTO vessel perforations carry the highest risk of complications and death.
Area of Science:
- Cardiovascular Medicine
- Interventional Cardiology
Background:
- Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is a complex procedure.
- Coronary artery perforation is a rare but serious complication of PCI.
Purpose of the Study:
- To investigate the epidemiology, mechanisms, management, and outcomes of coronary artery perforation during CTO PCI.
- To identify risk factors and consequences of coronary perforation in CTO PCI patients.
Main Methods:
- Retrospective analysis of 1,811 patients undergoing CTO PCI across five centers (2011-2018).
- Detailed review of perforation incidence, types (Ellis classification), causative approaches (antegrade vs. retrograde), interventions, and management strategies.
- Statistical analysis to determine factors associated with perforation and outcomes.
Main Results:
- Coronary perforation occurred in 5.5% of CTO PCI cases (n=99).
- Perforation was associated with older age, higher J-CTO scores, antegrade dissection/re-entry, retrograde approach, and lower success rates.
- Management included observation (47%), covered stents (25%), balloon occlusion (9%), and embolization (9%). Tamponade occurred in 20%, with in-hospital mortality of 5.1% in perforated cases versus 0.3% in non-perforated cases.
- Ellis type III perforations, particularly at the CTO site, were linked to tamponade and mortality.
Conclusions:
- Coronary perforation is a significant complication of CTO PCI, requiring intervention in over half of cases.
- Perforation is associated with increased rates of tamponade and mortality, especially when related to the CTO vessel.
- Risk factors include older age, longer occlusions, and specific PCI techniques like retrograde approach and dissection/re-entry.
Aims:
The aim of this study was to describe the epidemiology, mechanisms, management, and outcomes of coronary artery perforation during chronic total occlusion (CTO) percutaneous coronary intervention (PCI).
Methods And Results:
We included 1,811 consecutive patients undergoing CTO PCI at five centres between 2011 and 2018. Coronary perforation was observed in n=99 (5.5%). Patients with perforation were older, had a higher J-CTO score, more often required antegrade dissection/re-entry and the retrograde approach, and had lower success rates. The frequency of Ellis type I, II, III and III "cavity spilling" perforations was 11%, 46%, 28%, and 14%, respectively. In 48% of cases, perforation involved the CTO vessel, while the retrograde approach was responsible for 46% of cases. In 53% of cases perforations required intervention. The most frequently applied management strategies included clinical observation (47%), covered stent implantation (25%), balloon occlusion (9%), and coil/fat embolisation (9%). Tamponade was observed in 20/99 (20%) perforation cases. Ellis type III perforations were most frequently observed at the CTO site. These were accountable for 16/20 tamponades and 3/5 deaths. In-hospital mortality was 5.1% vs 0.3% in patients with versus those without perforation (p<0.001). Older age, occlusion length >20 mm, rotational atherectomy, antegrade dissection/re-entry, and the retrograde approach were independently associated with coronary perforation. Patients with perforation suffered an increased incidence of target vessel failure on short-term follow-up.
Conclusions:
Coronary perforation is observed in a non-negligible proportion of CTO PCIs, often requires intervention, and is associated with tamponade and mortality in a minority of patients. CTO vessel-related perforations are associated with the highest burden of morbidity and mortality.
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