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A Detailed Analysis of Perforations During Chronic Total Occlusion Angioplasty
Taishi Hirai1, William J Nicholson2, James Sapontis3
1Saint Luke's Mid America Heart Institute, Kansas City, Missouri; Department of Medicine, Division of Cardiology, University of Missouri Kansas City, Kansas City, Missouri.
Insights
Coronary artery perforation during chronic total occlusion PCI is more common with retrograde approaches. Larger size, proximal location, and high-risk shapes increase the risk of major adverse cardiac events.
Area of Science:
- Interventional Cardiology
- Cardiovascular Research
- Medical Imaging
Background:
- Coronary artery perforation incidence is higher in chronic total occlusion percutaneous coronary intervention (CTO PCI) than non-CTO PCI.
- Retrograde procedures exhibit the highest perforation rates within CTO PCI.
Purpose of the Study:
- To characterize angiographic features of perforations during CTO PCI.
- To identify strategies associated with perforation occurrence.
- To describe management and outcomes of CTO PCI-related perforations.
Main Methods:
- Analysis of a 12-center registry of 1,000 consecutive CTO PCI patients.
- Core lab adjudication of 89 angiographic perforations (8.9% incidence).
- Classification of perforations as clinical (requiring treatment) or observed, and assessment of major adverse cardiac events (MAEs).
Main Results:
- 48.3% of perforations were clinically significant; 51.7% were observed.
- Major adverse cardiac events occurred in 28.0% of patients, with in-hospital death in 10.1%.
- Clinical perforations and those associated with MAEs were larger, more proximal or collateral, and had high-risk shapes.
Conclusions:
- Larger size, proximal/collateral location, and high-risk shapes are associated with major adverse cardiac events following coronary perforation.
- Antegrade approaches accounted for a significant proportion of perforations, even when retrograde strategies were attempted.
- Findings aid operators in recognizing high-risk perforation features and inform comparative analyses of antegrade vs. retrograde complications.
Objectives:
This study sought to describe the angiographic characteristics, strategy associated with perforation, and the management of perforation during chronic total occlusion percutaneous coronary intervention (CTO PCI).
Background:
The incidence of perforation is higher during CTO PCI compared with non-CTO PCI and is reportedly highest among retrograde procedures.
Methods:
Among 1,000 consecutive patients who underwent CTO PCI in a 12-center registry, 89 (8.9%) had core lab-adjudicated angiographic perforations. Clinical perforation was defined as any perforation requiring treatment. Major adverse cardiac events (MAEs) were defined as in-hospital death, cardiac tamponade, and pericardial effusion.
Results:
Among the 89 perforations, 43 (48.3%) were clinically significant, and 46 (51.7%) were simply observed. MAE occurred in 25 (28.0%), and in-hospital death occurred in 9 (10.1%). Compared with nonclinical perforations, clinical perforations were larger in size, more often at a collateral location, had a high-risk shape, and less likely to cause staining or fast filling. Compared with perforations not associated with MAE, perforations associated with MAE were larger in size, more proximal or at collateral location, and had a high-risk shape. When the core lab attributed the perforation to the approach used when the perforation occurred, 61% of retrograde perforations by other classifications were actually antegrade.
Conclusions:
Larger size, proximal or collateral location, and high-risk shapes of a coronary perforation were associated with MAE. Six of 10 perforations occurred with antegrade approaches among patients who had both strategies attempted. These finding will help emerging CTO operators understand high-risk features of the perforation that require treatment and inform future comparisons of retrograde and antegrade complications.
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