Conservative Management of Coronary Perforation: Lessons from the Oleander Bloom

Coronary artery perforation is a rare but serious complication of percutaneous coronary interventions (PCI). We reviewed our database for cases of overt coronary perforation during PCI procedures. Hospital charts, procedural reports, and coronary angiograms of these patients were reviewed, with particular emphasis on mechanisms of perforation, management of the complication, and clinical outcome. Between 01/1998 and 12/2003, a total of 19 cases (mean age: 66+/-8 years, 13 male) of coronary perforation occurred during 6433 PCI procedures performed within this period (incidence: 0.3%). In 12/19 (63%) cases, perforation occurred during recanalisation procedures of chronic total occlusions of coronary arteries. In all but one patient, non-surgical management was attempted: 2 out of 19 (11%) patients were treated conservatively by reversal of heparin anticoagulation. Prolonged balloon inflation at the perforation site was applied in 10/19 (53%) patients. Six (32%) patients received stents (5 of them received covered stentgrafts), 3 (16%) patients developed cardiac tamponade requiring percardiocentesis, and only 2 (11%) patients underwent bailout surgical repair. There were 2 (11%) deaths early after the procedure. Coronary perforation during PCI is a rare complication, but is associated with significant morbidity and mortality. In the majority of patients, non-surgical management is both feasible and associated with a high success-rate.

P6526Short and long-term outcomes of coronary perforation managed by coil embolization: a single-center experience

Long-term outcomes of iatrogenic coronary dissection and perforation in patients undergoing percutaneous coronary intervention (PCI) remains under-investigated. We analyzed 8,721 consecutive patients discharged after PCI between 2008 and 2019 from Keio Cardiovascular (KiCS) PCI multicenter prospective registry in the Tokyo metropolitan area. Significant coronary dissection was defined as persistent contrast medium extravasation or spiral or persistent filling defects with complete distal and impaired flow. The primary outcome was a composite of all-cause death, acute coronary syndrome, heart failure, bleeding, stroke requiring admission, and coronary artery bypass grafting two years after discharge. We used a multivariable Cox hazard regression model to assess the effects of these complications. Among the patients, 68 (0.78%) had significant coronary dissections, and 61 (0.70%) had coronary perforations at the index PCI. Patients with significant coronary dissection had higher rates of the primary endpoint and heart failure than those without (25.0% versus 14.3%, P = 0.02; 10.3% versus 4.2%, P = 0.03); there were no significant differences in the primary outcomes between the patients with and without coronary perforation (i.e., primary outcome: 8.2% versus 14.5%, P = 0.23) at the two-year follow-up. After adjustments, patients with coronary dissection had a significantly higher rate of the primary endpoint than those without (HR 1.70, 95% CI 1.02–2.84; P = 0.04), but there was no significant difference in the primary endpoint between the patients with and without coronary perforation (HR 0.51, 95% CI 0.21–1.23; P = 0.13). For patients undergoing PCI, significant coronary dissection was associated with poor long-term outcomes, including heart failure readmission.

Incidence, Mechanisms, Treatment, and Outcomes of Coronary Artery Perforation During Chronic Total Occlusion Percutaneous Coronary Intervention

Coronary perforation is an uncommon but potentially life-threatening complication of percutaneous coronary intervention. The use of both atheroablative technologies for coronary intervention and adjunctive platelet glycoprotein blockade pharmacology may increase the incidence of or risk for life-threatening bleeding complications following the occurrence of coronary artery perforation. The interventional database for 6,214 percutaneous coronary interventions performed between January 1995 and June 1999 was analyzed. Hospital charts and cine angiograms for all patients identified in the database as having had coronary perforation were reviewed. Coronary perforation complicated 0.58% of all procedures and was more commonly observed in patients with a history of congestive heart failure and following use of atheroablative interventional technologies (2.8%). There was no association of abciximab therapy with either the incidence of or classification for coronary perforation. Adverse clinical outcomes (death, emergency surgical exploration) were related to the angiographic classification of perforation and were more frequently observed in patients who experienced a class 3 coronary perforation. These data suggest that specific clinical and procedural demographic factors are associated with the occurrence and severity of angiographic coronary perforation. An angiographic perforation class-specific algorithm for treatment of coronary perforation is proposed.

Coronary perforation is a potentially life-threatening complication of percutaneous coronary intervention (PCI). We studied incidence, outcomes and temporal trends following PCI-related coronary artery perforation (CAP).MethodsProspective systematic review and meta-analysis including...

Case seriesPatients: Male, 51-year-old • Male, 72-year-oldFinal Diagnosis: Coronary diseaseSymptoms: Chest painClinical Procedure: —Specialty: CardiologyObjective:Unusual clinical courseBackground:Coronary artery perforation is a rare complication of percutaneous coronary intervention for coronary artery occlusion. This report is of 2 cases of coronary artery perforation during percutaneous coronary intervention that were managed successfully using injection of combined Histoacryl (n-Butyl-2-Cyanoacrylate) and Lipiodol (ethiodized oil).Case Reports:Case 1 was a 51-year-old man with a past medical history of hypertension, dyslipidemia, and multivessel coronary disease. He was admitted to our hospital with inferior wall myocardial infarction, and a stent was placed in the proximal right coronary artery. He also had chronic total occlusion (CTO) of the left anterior descending artery (LAD). The planned LAD CTO intervention was complicated by balloon-induced coronary perforation and was managed successfully with intracoronary injection of Histoacryl-Lipiodol mixtures via microcatheter. He was discharged in stable condition without any serious consequences. Case 2 was a 72-year-old man with underlying hypertension who was admitted to the hospital with diagnosis of unstable angina. The diagnostic angiography showed occlusion of the LAD, CTO of the left circumflex artery, and minor atherosclerosis in right coronary artery. A stent was placed in the mid-LAD without any complications. Subsequently, a planned left circumflex artery CTO intervention was complicated by wire-induced coronary perforation, which was treated successfully with injection of Histoacryl-Lipiodol mixture. The patient was discharged in good condition.Conclusions:Histoacryl and Lipiodol injection was a rapid and effective management method in 2 rare cases of coronary artery perforation during percutaneous coronary intervention.

Fate of Patients With Coronary Perforation Complicating Percutaneous Coronary Intervention (from the Euro Heart Survey Percutaneous Coronary Intervention Registry)

Coronary perforation incidence and temporal trends (COPIT): systematic review and meta-analysis

Coronary perforation is an uncommon complication of percutaneous coronary intervention (PCI), that, in extreme cases, might result in cardiac tamponade. Here, we describe a case of coronary artery perforation in a 55-year-old female, presented with recent inferior wall myocardial infraction (IWMI). Coronary angiogram represented right coronary artery (RCA) lesion which was planned to manage with PCI. During PCI, coronary perforation emerged in RCA, leading to cardiac tamponade. Hence an immediate pericardiocentesis was performed and coronary perforation was tackled successfully using a covered stent. Keywords: Coronary perforation, percutaneous coronary intervention (PCI), cardiac tamponade, cath lab nightmare.

Objective To evaluate the long-term efficacy of covered stent implantation to the patients with coronary perforation occurred in percutaneous coronary intervention (PCI). Methods From June 2004 to March 2011, a total of 8 cases received 8 covered stents implantation because of coronary perforation in our centre. Ellis grade III coronary perforation occurred in 7 patients, and Ellis grade I in 1 patient. The patients took clopidogrel 75 mg/d for 2 years, and 100 mg/d for lifetime. The major adverse cardiac events (MACE) were observed in the 8 patients through long-term follow-up. Results There were 5 males and 3 females in the 8 patients who aged 63–76 (mean 69.3 ± 4.7) years. Six patients had multi-vessel disease. The target vessels were left anterior descending artery (LAD) in 7 patients. Calcified lesions emerged in 3 patients and total occlusion lesions in 3 patients. In addition to 2 patients with balloon dilating after guidewire into the false lumen, the coronary artery perforation of the remaining six patients were associated with too high pressure of stent expansion or balloon dilating. Pericardial tamponade happened in 7 patients, and pericardial effusion of 100–470 ml was drained by pericardiocentesis. Implanted covered stents average diameter was 3.3 ± 0.3mm, and average length was 21.3 ± 4.1mm. All perforation of the patients were successfully closed, while no patients died in PCI. During follow-up of 0.6–67 months (mean 35.3 ± 25.1 months), 2 patients died. Nineteen days after PCI, one patient died of multiple organ failure due to lung infection. Thirteen months after PCI, another patient died of cardiac sudden death. One patient was hospitalised with angina pectoris after 53 months, and the symptoms was relieved. The imaging was not reviewed. After 6 months one patient received multi-slice CT examination, and no restenosis was found. He was currently asymptomatic. The remaining four patients were reviewed coronary angiography after 15–67 months. Only one patient showed LAD stent restenosis and received target vessel revascularization. The remaining 3 patients had no restenosis within the stent. During the entire follow-up, restenosis rate was 20% (1/5), mortality rate was 25% (2/8) and MACE rate was 50% (4/8). If follow-up after PCI was 12 months, MACE rate decreased to 25% (2/8). Conclusions Treatment of covered stent to coronary perforation can achieve good long-term efficacy. A two-year dual antiplatelet drugs can be effective in preventing covered stent thrombosis.

ObjectivesTo evaluate the long-term efficacy of covered stent implantation to the patients with coronary perforation occurred in percutaneous coronary intervention (PCI).MethodsFrom June 2004 to March 2011, a total of 8...

Short and long-term outcomes of coronary perforation managed by coil embolization: A single-center experience

Introduction Coronary artery perforation is a serious complication during percutaneous coronary intervention that results in significant increase in morbidity and mortality. In this article, we provide a state-of-the-art overview of the contemporary management of coronary perforation and the possible scenarios that operators may run into during percutaneous coronary interventions. Area covered Coronary perforation during percutaneous coronary intervention. Literature search was performed using PubMed and Google Scholar to identify the most recently published articles covering this topic. Expert opinion As part of this review, we also provide an expert commentary discussing the nuances in the recognition and management of coronary artery perforation, in addition to future directions, and improvements in technology that could make the management of coronary perforation safer and more effective.

To evaluate the outcome of patients with coronary perforations who were treated with the dual catheter approach. Coronary artery perforation is a grave complication of percutaneous coronary intervention (PCI) with high mortality and morbidity. Treating a coronary artery perforation with two catheters through dual access enables a rapid delivery of covered stent or coils to the vessel, without losing control of the perforation site. We retrospectively reviewed all patients who had a severe coronary perforation during a PCI in our center, and compared outcomes of patients treated with the dual versus the traditional single guiding catheter approach. Between April 2004 and October 2008, 13,466 PCI's were performed in Columbia University - New York Presbyterian Medical Center. There were 33 documented cases of coronary perforations during that period of time (0.245%), among these, 26 were angiographically severe (Ellis type 2 or 3 perforations). Eleven patients were treated acutely with a dual catheter technique whereas the other fifteen patients were treated using a single guiding catheter. In the dual catheter group one patient expired after emergent CABG (9.1%), and four patients underwent emergent paricardiocentesis (36.4%). In patients treated with single catheter, there were three deaths (20%), two surgical explorations (13.3%), eight emergent pericardiocenthesis (53.3%), and one event of severe anoxic brain damage (6.7%). The dual catheter technique is a relatively safe and reproducible approach to treat a PCI induced severe coronary artery perforation, and may improve outcome compared to historical series.