Case Of Coronary Artery Perforation Research Articles

Heparin reversal for coronary artery perforation

Abstract Background/Introduction In the management of coronary artery perforation (CAP) during percutaneous coronary intervention (PCI), heparin reversal can provide hemostatic effects but raises concerns about potential coronary thrombosis if an intracoronary artery guidewire or balloon is in place. Purpose We aimed to evaluate the safety and efficacy of heparin reversal during device insertion for CAP. We also aimed to determine the optimal target activated clotting time (ACT) to maintain when performing heparin reversal. Methods We analyzed cases of CAP which occurred during PCI procedures in a single center from January 2006 to October 2023. Patients were assigned to two groups according to whether they received heparin reversal with a device in place. The safety outcome was the periprocedural myocardial infarction (creatine kinase-MB >5 times the upper normal limit), and the efficacy outcome was successful hemostasis at the end of the procedures (complete absence of CAP on angiography). Results Among the 22,368 cases, 368 (1.6%) developed CAP, consisting of main vessels 45%, distal vessels 43%, and collateral vessels 12%. Heparin reversal with a device in place was implemented in 211 (57%) cases. Of these, 16 (7.6%) experienced coronary thrombosis. After adjusting covariates by the multivariable logistic regression model, heparin reversal with a device in place was significantly associated with a higher incidence of periprocedural myocardial infarction (11% vs 4.5%; adjusted OR: 3.11; 95% CI: 1.24–7.78; P = 0.015) and a higher rate of successful hemostasis (91% vs 73%; adjusted OR: 2.78; 95% CI: 1.27–6.09; P = 0.011). In the analysis of cases where minimum ACT value was available (n = 251), this value was significantly correlated with coronary thrombosis (r = −0.16, P = 0.012). When the cutoff values of minimum ACT were set at 200, 150, and 120 seconds as a binomial variable, the correlation coefficient was r = −0.08 (P = 0.158), r = −0.16 (P = 0.009), r = −0.20 (P = 0.001), respectively. Conclusions Heparin reversal after CAP with an intracoronary artery device in place was significantly associated with a higher incidence of periprocedural MI but also a higher rate of successful hemostasis. A minimum ACT value <150 seconds was significantly correlated with coronary thrombosis. These results propose a novel algorithm for CAP management strategies.Management algorithm for CAP

Sealing of Iatrogenic Distal Coronary Artery Perforation by Liquid Embolization Agent—A Case Report

Percutaneous coronary intervention (PCI) is one of the most commonly performed cardiovascular interventions to treat significant coronary artery stenosis. Although a safe procedure, it carries the risk of complications like coronary artery perforation (CAP), bleeding, stroke, and acute kidney injury rarely resulting in death. The incidence of CAP is 0.84% of all PCI procedures and the incidence is increasing as cardiologists are accepting more and more challenging cases. CAP is caused by a guidewire (GW) or a vessel tear from balloon angioplasty, stenting, or rotational atherectomy. Though the majority of CAPs do not result in cardiac tamponade, some do lead to tamponade and death. The majority of distal wire perforations respond to prolonged balloon inflation, coils, glue, or fat embolization. Herein, we report a case of distal CAP in a 63-year-old woman occurring following left circumflex artery PCI caused by the exiting of coronary GW. The CAP was successfully sealed by the liquid embolization technique using ONYX. First described in 1990, Onyx is an elastic polymer composed of ethylene vinyl alcohol copolymer dissolved in dimethyl sulfoxide and mixed with micronized tantalum powder (Onyx). The Onyx is predominantly used by interventional radiologists while performing neurovascular and peripheral vascular interventions. There were only a few case reports of plugging of CAPs using Onyx. Our case highlights the safety and feasibility of closing distal CAPs using Onyx.

Coronary Perforation with Emergence of Cardiac Tamponade During Coronary Intervention - A Cath Lab Nightmare

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.

Serial observation of PK Papyrus covered stent implantation for coronary artery perforation by optical coherence tomography and coronary angioscopy: a case report

Abstract Background Coronary artery perforation is a rare but life-threatening complication of percutaneous coronary intervention. We present a case of coronary artery perforation treated with a PK Papyrus covered stent. Neointimal coverage evaluation was performed using optical coherence tomography (OCT) and coronary angioscopy (CAS) at 3 and 9 months after stent implantation. Case summary A 63-year-old man was admitted to our hospital with worsening effort angina over 3 months. Coronary angiography revealed severe stenosis in the proximal segment of the left anterior descending artery. After stent implantation, coronary artery perforation occurred. We immediately sealed the perforation site using a PK Papyrus covered stent. The patient was discharged on postoperative day 4. OCT and CAS revealed incomplete neointimal coverage at the PK Papyrus covered stent strut 3 months after stent implantation. At 9 postoperative months, complete neointimal coverage was observed. We continued clopidogrel and edoxaban, but no clinical adverse events were encountered during the follow-up. Discussion To the best of our knowledge, this is the first report of a serial observation of PK Papyrus covered stent implantation for coronary artery perforation using OCT and CAS. In this case, OCT and CAS revealed complete neointimal coverage, without obvious thrombus, 9 months after PK Papyrus implantation. Based on the OCT and CAS findings, our report presents an appropriate follow-up strategy for the prevention of stent thrombosis when using a PK Papyrus covered stent, which will contribute to future research on the appropriate duration of dual antiplatelet therapy and evaluation of neointimal coverage.

Coronary artery perforation after bioresorbable scaffold implantation treated with a new generation covered stent\u2014OCT insights

BackgroundCoronary artery perforation is a rare but potentially lethal complication of percutaneous coronary intervention (PCI) with an associated mortality of 7–17%. We report the case of coronary artery perforation complicating Absorb bioresorbable vascular scaffold (BVS) implantation and the associated technical challenges with managing this life-threatening complication.Case reportA 46-year-old male was referred to our institution and underwent PCI with an Absorb bioabsorbable vascular scaffold (BVS) to a proximal LAD long segment bifurcation lesion. Following pre-dilation and deployment of the 3.5 × 28 mm Absorb BVS, high pressure post-dilation of the distal scaffold was complicated by a large, Ellis type III coronary perforation with no flow to the distal LAD beyond the rupture, and associated with a large pericardial effusion confirmed on bedside transthoracic echocardiogram (TTE). The insult was temporised with prolonged balloon inflation within the Absorb BVS immediately proximal to the site of perforation, permitting urgent insertion of a pericardial drain. After deflation of the balloon, a 3.0 × 21 mm BeGraft covered stent was deployed across the perforation, restoring normal LAD flow and abolishing the perforation. Cardio-pulmonary resuscitation was not required and the patient remained conscious throughout the procedure. TTE demonstrated normal left ventricular function and the patient was discharged 3 days later. Repeat angiography at 3 months showed patent stents with TIMI III flow, and optical coherence tomography (OCT) showed good expansion and apposition of the proximal Absorb BVS and BeGraft. The patient has remained well 4 years after PCI with no major cardiovascular events.ConclusionThe utility of bioresorbable scaffold technology remains controversial although meticulous implantation techniques are associated with improved clinical outcomes. Adoption of the Pre-dilatation, Sizing and Post-dilatation (‘PSP’) method of BVS implantation with routine aggressive vessel preparation and scaffold optimization however may contribute to a higher risk of vessel perforation. The case emphasises the importance of accurate sizing of the vessel with intracoronary imaging and demonstrates the value of newer generation covered stents with single-layer design and slimmer crossing profile producing improved deliverability and procedural success.

Coronary Artery Perforation and Tamponade - Incidence, Risk Factors, Predictors and Outcomes From 12 Years' Data of the SCAAR Registry.

The incidence and short- and long-term outcomes of coronary artery perforation (CAP) are not well described. We analyzed the characteristics and the short- and long-term outcomes of CAP among 243,149 patients undergoing percutaneous coronary interventions (PCI) from 2005 until 2017 in the national Swedish registry. We identified 1,008 cases of CAP with an incidence of 0.42%. Major adverse event rates were significantly higher in patients with CAP than non-CAP (P<0.001). The 1-year mortality rate was 16% vs. 5.5%, respectively, and the 12-year mortality rate was 52% vs. 34%. The restenosis rate was 5.2% vs. 3.1% and 17% vs. 9%, respectively. The target lesion revascularization rate was 4.2% vs. 2.6% and 10.5% vs. 7%. The stent thrombosis rate was numerically higher, 1.5% vs. 0.8% and 4.5 vs. 2.8%, with no stent thrombosis cases for equine pericardial stent grafts. Among the patients with tamponade a large proportion of cases occurred at the late stage (215/1,008, 21%), and most were not recognized in the cath-lab (167/215, 78%). The mortality rate for late tamponade was similar in patients suffering acute tamponade at 1 year (25.6% vs. 27%) or at 12 years (54% vs. 58%). CAP is associated with an early high excess in morbidity and mortality but with low risk of additional adverse events in the long term. Late tamponade is as deadly as acute tamponade.

Single Center 7 Year Experience of Coronary Artery Perforation: Angiographic and Procedural Characteristics, Management and Outcome.

Context:Coronary artery perforation is a rare but potentially catastrophic complication of percutaneous coronary intervention (PCI). It is infrequent complication of PCI.Aims:The objective of the study is to report the 7-year experience of coronary artery perforation with respect to incidence, clinical and angiographic characteristics, management and outcomes.Settings and Design:The study involved retrospective analysis of single centre 7 years of percutaneous coronary intervention data. Patients who had complication of coronary artery perforation during PCI were identified and included in the study.Subjects and Methods:Retrospective analysis of clinical, angiographic and procedural characteristics as well as management and outcome of coronary artery perforation was done.Statistical Analysis Used:The whole data were tabulated, variables were presented as mean and percentages and comparison was done within them.Results:A total of 37 cases of coronary artery perforation were identified from 4532 PCI performed. Most of the coronary artery perforation belonged to Ellis Type II and Type III (both n = 15) followed by Type III CS and Type I. Lesions belonged to AHC/AHA Type C in 31 cases. Most frequent mechanism of coronary artery perforation was related to the use of guidewire and balloon (both n = 17). The total of 8 cases presented with cardiac tamponade requiring pericardiocentesis. Eleven cases required emergency covered stent implantation. In two cases microcoil was used while one case required polyvinyl alcohol particles to seal the perforation site. There was no in-hospital mortality while 30-day mortality occurred in one patient. One case was referred for emergency surgery.Conclusions:Coronary artery perforation is rare but potentially fatal complication of percutaneous coronary intervention. Complication of coronary artery perforation can be managed effectively in the catheterization laboratory without the need of emergency of bailout surgery and in-hospital outcomes remain good in the majority of cases.

Coronary Artery Perforation During Percutaneous Coronary Intervention in a Patient with a Prior Modified Bentall Procedure.

The Bentall procedure is a surgical technique for an ascending aortic or aortic aneurysm in combination with valve disease. A well-known uncommon complication of after the Bentall procedure is coronary artery stenosis related to coronary anastomosis of an interposed graft. We report on a 73-year-old woman who presented with heart failure secondary to graft stenosis of the right coronary artery 6 months after undergoing a modified Bentall procedure. Percutaneous coronary intervention (PCI) was performed and type II coronary artery perforation occurred during PCI of the right coronary artery. We used a perfusion balloon and achieved hemostasis successfully. We report a case of coronary artery perforation that was treated with perfusion balloon during PCI in a patient with a prior modified Bentall procedure. In addition, we present a case series of PCI for ostial coronary stenosis after the Bentall procedure.

Management and outcomes of coronary artery perforations during percutaneous treatment of acute coronary syndromes.

Coronary artery perforation (CAP) is an infrequent and life-threatening complication of percutaneous coronary intervention (PCI), requiring prompt intervention. There is insufficient data about the prognosis and management of CAP in patients with acute coronary syndrome (ACS). The aim of this study was to investigate the management of CAP in patients with ACS. The results of 25 patients with CAP were retrospectively analyzed. Of the 25 patients, 14 patients (56%) had ACS. According to the Ellis classification, the grade of perforation was type-I in 8 (32%) patients, type-II in 6 (24%) patients and type-III in 11 (44%) patients. Prolonged balloon inflation was performed to 20 (80%) cases of CAP. It successfully sealed the perforation in three cases of type-I, five cases of type-II CAP and in seven cases of type-III CAP. Seven patients underwent covered stent implantation. Emergent CABG was required in two patients with type-III CAP. In-hospital mortality was not observed in the patients. The outcomes of CAP in patients with ACS were similar to patients with stable coronary disease. The continuation of anti-platelet agents after the successful management of CAP may be encouraged in these patients.

An unusual case of distant coronary artery perforation

Coronary perforations are likely in complex lesions like calcified coronaries or chronic total occlusions. The management is challenging in the face of hemodynamic instability. We are reporting an unusual case of coronary artery perforation. After an unsuccessful attempt to pass a guide wire in chronically occluded branch of the diagonal artery, there was type II perforation which sealed off by itself. After the procedure the patient developed cardiac tamponade for which pericardiocentesis was done. After initial improvement in hemodynamics the patient developed signs of tamponade again with continuous drainage of blood from pericardial space. A check shoot, surprisingly showed a type III perforation in the distal LAD! No hardware had been passed into the distal LAD. Retrospectively it was thought that the cause was the pericardiocentesis needle which had nicked the LAD during pericardiocentesis.

Successful management of coronary artery rupture with stent-graft: a case report.

Perforation of coronary arteries is a relatively rare yet life-threatening complication of percutaneus coronary interventions and is encountered in approximately 0.5% of these procedures. According to the type of coronary perforation, various methods of correction are employed, ranging from conservative approach to emergency cardiac surgery. Coronary stent-grafts are composed of two metal stents and a polytetrafluoroethylene layer between them. Advent of such stents enabled efficient endovascular repair of coronary artery perforation. We present a case of coronary artery perforation which had occurred during stent implantation for the treatment of a bridged segment in the distal portion of the left anterior descending artery. This perforation was successfully managed by implanting a stent-graft.

A unique and unexplained ricochet leak post PCI – Successfully treated with intra-coronary glue

We herein describe a unique case of coronary artery perforation treated with covered stent with repeat cardiac tamponade resulting out of a fresh unexplained leak from a remote vessel (Ricochet) and successfully treated with intra-coronary injection of sterile synthetic glue, cyanoacrylate.

Failed thrombin treatment due to patent collateral leakage after refractory guidewire-induced coronary artery perforation

Ellis class III coronary artery perforation is a rare but catastrophic complication associated with high mortality and poor outcome of percutaneous coronary intervention. We describe a case of coronary artery perforation caused by a stiff hydrophilic guidewire during percutaneous coronary intervention. Leakage from patent collaterals continued despite successful embolism of the perforated artery. Although he underwent cardiac surgery, the patient died due to the rupture of a left ventricular pseudoaneurysm.

Coronary artery perforations: Four different cases and a review

Coronary artery perforation (CAP) is a rare but feared complication of percutaneous coronary intervention. With the advent of new devices and technologies, interventionalists attempt more complex lesions, including more calcified or tortuous vessels and chronic total occlusions, which increases the incidence of CAP. A short literature review, in addition to four cases of CAP, is presented in this report.

Coronary artery perforations: Four different cases and a review

Coronary artery perforation (CAP) is a rare but feared complication of percutaneous coronary intervention. With the advent of new devices and technologies, interventionalists attempt more complex lesions, including more calcified or tortuous vessels and chronic total occlusions, which increases the incidence of CAP. A short literature review, in addition to four cases of CAP, is presented in this report.

S Coronary artery perforation during diagnostic coronary angiography resulting in acute pericarditis

We report a case of coronary artery perforation during diagnostic coronary angiography. No cardiac biomarker elevation was observed. However, the patient suffered acute pericarditis which was treated conservatively.

A case of coronary artery perforation with successful hemostasis using over-the-wire balloon and autologous blood perfusion

Advances in coronary intervention have increased the opportunity to intervene on complex lesions, resulting in an increase in PCI-related complication, including coronary artery perforation. However, treatment options for coronary perforation are limited, with delivery of devices to complex lesions being problematic. Balloon hemostasis is the usual bailout method, despite the risk of myocardial ischemia. In this report, we describe an over-the-wire balloon method to treat a patient with coronary perforation. Ischemia was avoided by injecting autologous blood through the catheter, while hemostasis was achieved by prolonged balloon inflation. This new technique is applicable when a perfusion balloon is not indicated.

Coronary Artery Perforation Successfully Treated With Tris-acryl Gelatin Microsphere Embolisation

We describe a case of coronary artery perforation in a 76-year-old man, successfully treated by tris-acryl gelatin microsphere embolisation. This novel interventional embolic material is used in interventional radiology for arterial embolisation. We believe that this is the first report of its use for a coronary artery perforation.

Incidence, management, and outcome of coronary artery perforation during percutaneous coronary intervention

We have analyzed the incidence, management, and outcome of 84 cases of coronary artery perforation in patients who underwent percutaneous coronary intervention at our institution. This complication was more frequent in female patients and in patients who underwent lesion modification with atheroablative devices. A total of 8 patients (9.5%) died after the procedure. They were usually older and had a higher incidence of cardiac tamponade; a larger percentage of these patients underwent emergency surgery than those who survived.