Background: Percutaneous Coronary Intervention (PCI) is essential for coronary artery disease management. Coronary Artery Perforation (CAP), though rare (0.4% incidence), is a critical complication with high morbidity and mortality. As PCI techniques advance, understanding CAP outcomes becomes vital – particularly in resource-limited settings like Pakistan. This study at a major Pakistani tertiary center addresses local knowledge gaps and provides insights for managing this complication. Research Question: What are the angiographic and clinical characteristics of patients experiencing CAP during PCI, and what are the outcomes of different management strategies in-hospital and over long-term follow-up? Methodology: This single-center, retrospective observational study was conducted at Army Cardiac Center, Lahore. It included all CAP cases encountered during PCI over six years (January 2018 to December 2024). Patient and procedural data were collected from hospital records. Outcomes were categorized as in-hospital mortality and long-term endpoints: functional status (NYHA, CCS), repeat angiography, rehospitalization, and survival. Structured interviews and follow-up visits provided long-term data, which was analyzed using SPSS v28. Results: Thirty patients with CAP were identified (mean age 60.2 ± 1.57 years; 70% male). Common comorbidities were hypertension (73.3%) and diabetes (53.3%). The LAD was the most frequently involved vessel (63.3%). Most perforations resulted from non-compliant balloons and hydrophilic guidewires. Covered stents were used in 76.6%(n=23) of cases; balloon tamponade in 20%(n=6). Only two cases of significant pericardial effusion leading to cardiac tamponade were encountered. In-hospital mortality was 6.7%(n=2), with overall survival at follow-up of 86.7%(n=26). Functional outcomes were favorable (NYHA I: 56.7%, CCS I: 66.7%). Repeat angiography was needed in 10% of cases(n=3). Most patients (86.7%) were managed medically post-discharge, and 76.7% avoided rehospitalization. Conclusion: Our CAP mortality of 6.7% dramatically undercuts the 20% reported for Ellis III perforations. This outcome stems from our institutional protocol: leaving the balloon inside the stent with immediate safety testing (2 mL contrast injection) ,which enables instant inflation and tamponade during perforations. These results prove that systematic vigilance and rapid intervention optimize CAP outcomes—even in resource-limited settings

Background/Objectives: Despite the common use of invasive diagnostics and treatment of coronary artery disease (CAD), there are still doubts concerning the disease management method of choice in the population of very old patients. Our goal was to assess the patient profile, feasibility of coronary angiography (CAG), effectiveness (successful relieving of the coronary artery’s narrowing or occlusion) of percutaneous coronary intervention (PCI) and safety (mortality and other complications) of both procedures in nonagenarians. Methods: The database of the Dr. E. Warmiński Clinical Hospital of the Bydgoszcz University of Technology was searched for patients aged 90 years and older who underwent CAG and PCI between 2013 and 2023. We retrospectively analysed the case reports of these patients, including reason for hospital admission, course of hospitalisation, procedure data, and complications. Results: A total of 150 nonagenarians meeting the criteria were found, with a mean age of 92 years and 63% being female. A total of 110 patients (73%) were admitted on the basis of acute coronary syndrome (ACS). Upon CAG, 108 patients had obstructive coronary artery disease confirmed, 90% of whom had multivessel disease. In 96 out of 108 of these patients (that is, 89%), PCI was performed successfully in 89 (93%) procedures. Transradial access was used in 112 patients (75%). According to the diagnosis, PCI was performed in all cases (100%) of STEMI patients, in 80% cases of non-ST elevation acute coronary syndrome (NSTE-ACS) patients, and in 27% cases of stable CAD patients. Median time of hospitalisation was 6.5 days (IQR 4–10). In the course of hospitalisation, mortality was 8.7% (13 out of 150), although two cases were non-cardiological in nature. In the PCI group, mortality was 11.5% (11 out of 96); all 11 were treated due to ACS (no deaths in patients with stable ACS). In the STEMI subgroup, mortality was much higher at 33% (4 out of 12, with all 4 admitted with cardiogenic shock). Accordingly, in the NSTEMI group, mortality was 8.97%. Other complications in the PCI group were perforation of coronary artery in 1 case, access site complications in the case of transfemoral access in 10 patients, bleeding requiring transfusion in 2 patients, and contrast-induced nephropathy (CIN) in 4 patients. Conclusions: This analysis demonstrates that the CAG and PCI procedures are feasible and effective in nonagenarians, and the risk of complications is not as great as it was heretofore believed.

Background: Coronary artery perforation is a highly feared complication of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) and can lead to pericardial effusion, tamponade, and, rarely, emergent cardiac surgery. Perforation of coronary artery or epicardial collaterals during retrograde CTO-PCI may be particularly challenging to treat, as embolization from both sides of the perforation may be required to control the bleeding. However, only conservative measures in selected cases can be effective. We report a case of distal posterior descending (PD) branch of left circumfl ex (LCX) artery vessel perforation that was managed conservatively with anticoagulation reversal. Case Summary: An 85-year-old Caucasian male patient, with a history of lateral and inferior myocardial infarction and previous PCI, underwent a planned coronary arteriography due to progressive angina. Coronary angiography revealed normal function of implanted drug eluting stents (DES) in the mid-LAD and in the proximal right coronary artery (RCA) and CTO of dominant LCX. A septal branch in the midsegment of LAD was supplying the distal PD of LCX retrogradely. After failed attempt at antegrade PCI for the LCX’s CTO, the retrograde approach was tried. This intervention fi nally succeeded through the septal collateral but after removing the retrograde guidewire with the support of microcatheter, vessel perforation of distal PD of LCX was observed. This complication was successfully managed conservatively with anticoagulation reversal. Post-operatively, the patient had no complications and was stable at 6-month follow-up. Discussion: Coronary artery perforation can be managed conservatively only with anticoagulation reversal in selected cases.

TCT-950 Clinical Outcomes of Coronary Artery Perforation Treated with Covered Stents: The Impact of Intravascular Ultrasound Guidance in a Contemporary Cohort

Clinical Experience With a Novel Perfusion Balloon Catheter in Patients With Coronary Artery Perforation: Primary Results From the Ringer Clinical Study

BACKGROUND: Hypertrophic cardiomyopathy is a primarily genetically determined myocardial disease characterized by pronounced, often asymmetric, myocardial hypertrophy that results in diastolic dysfunction and left ventricular outflow tract obstruction. Septal alcohol ablation is a contemporary, minimally invasive interventional approach to the treatment of this condition. AIM: To evaluate the effectiveness of septal alcohol ablation and the progression of heart failure in patients following the procedure. MATERIALS AND METHODS: A single-group, open-label study was conducted to evaluate the outcomes of septal alcohol ablation in patients with hypertrophic cardiomyopathy and left ventricular outflow tract obstruction resistant to pharmacologic therapy. All patients were hospitalized at St. Petersburg City Multidisciplinary Hospital No. 2 between September 2021 and February 2024. Among the 157 patients diagnosed with hypertrophic cardiomyopathy, only 65 met the inclusion criteria. The effectiveness of septal alcohol ablation was assessed based on normalization of the peak pressure gradient in the left ventricular outflow tract and improvement in clinical status, evaluated at hospital discharge, three months’ post-procedure, and during a follow-up visit in February 2024. RESULTS: A significant reduction in the peak pressure gradient in the left ventricular outflow tract was observed in postoperative patients following septal alcohol ablation — from 81.5 to 21.3 mm Hg (p=0.000001). Interventricular septal thickness decreased from 21.6 to 19.6 mm, left ventricular ejection fraction increased from 63.3 to 65.1%, and left ventricular end-diastolic diameter changed from 42.6 to 42.1 mm (p=0.62). No intraoperative complications such as coronary artery perforation, cardiac tamponade, or access site hematoma were reported. Major cardiovascular events within one year after septal alcohol ablation occurred in 12 patients (18.5%), including 9 cases (13.8%) of heart failure decompensation and 2 cases (3.1%) of myocardial infarction. A statistically significant improvement in New York Heart Association functional class was observed — from class III–IV to class I–II (p=0.0009). CONCLUSION: Septal alcohol ablation has proven to be an effective and safe treatment modality for obstructive hypertrophic cardiomyopathy, provided that appropriate patient selection is ensured.

Chronic Immunosuppression May Increase the Risk of Coronary Artery Perforation in Patients Undergoing CTO-PCI

Coronary artery ectasia (CAE), characterized by diffuse dilation, can be associated with total thrombotic occlusion, leading to acute coronary syndrome. In such cases, distal vessel morphology can be highly unpredictable, potentially causing confusion during percutaneous coronary intervention (PCI). A 47-year-old man presented with sudden chest pain. Acute coronary syndrome was suspected based on symptom and elevated troponin I levels. Coronary angiography revealed diffuse CAE and total occlusion of mid-left circumflex artery. Due to the large thrombus, aspiration thrombectomy, intracoronary abciximab, and repeated balloon angioplasty were performed. After these procedures, there was absence of flow beyond the lesion, and huge extravasation around the vessel, resembling a coronary artery perforation. Considering various factors, we concluded it was not a perforation and subsequently performed intravascular ultrasound-guided PCI on the ectatic culprit vessel. After successful PCI, he was discharged on aspirin and clopidogrel. Due to heartburn, dual antiplatelet therapy was de-escalated to clopidogrel monotherapy after 6 months. During the follow-up, he remained stable, and a 9-month coronary angiography confirmed patent stent without lesion progression. Stagnant flow in dilated vessels can cause local dye deposition, which may resemble procedure-induced perforation or dissection, necessitating heightened caution during PCI. Intravascular ultrasound is valuable for accurate assessment of lesions in CAE. Thrombectomy and glycoprotein IIb/IIIa inhibitors would be considered to manage high thrombus burden. Due to its diverse clinical presentations, CAE requires an individualized strategy, and can also be treated with simple PCI followed by dual antiplatelet therapy.

D-52 | Comparative Outcomes of Papyrus and GraftMaster Covered Stents in the Management of Coronary Artery Perforation: A Retrospective Analysis

Coronary artery perforation is a rare but potentially fatal complication during percutaneous coronary intervention. In this case, we report a patient with myocardial infarction who experienced coronary perforation during percutaneous coronary intervention and successful application of the graft stent. In our case, coronary rupture occurred as a result of balloon inflation in a small vessel without making sure that the guidewire was in the lumen. Prolonged balloon inflation at the site of coronary perforation may provide a solution in some cases. In our case, the balloon was inflated proximal to the rupture, the bleeding was stopped by waiting, and the coronary rupture was successfully closed with a graft stent. The balloon or stent balloon should not be inflated without making sure that the coronary lumen is in place. If inflated without being sure, coronary rupture may occur. Steps to manage this complication include rapid closure of the perforated area, administration of protamine sulfate, graft covered stenting and emergency surgery if necessary.

Rationale:Coronary artery disease remains a leading cause of morbidity, requiring complex revascularization strategies, especially in patients with heavily calcified lesions. Percutaneous coronary intervention (PCI) is a common treatment, but it carries risks such as coronary artery perforation and the rare Kokeshi phenomenon during rotational atherectomy (RA). This study aims to emphasize the challenges faced in treating heavily calcified coronary lesions, specifically focusing on the rare Kokeshi phenomenon and coronary artery perforation during RA.Patient concerns:We report the case of a man in his 70s with a history of type 2 diabetes mellitus, atrial fibrillation, and chronic obstructive pulmonary disease, who presented with non-ST elevation myocardial infarction.Diagnoses:Coronary angiography showed the culprit lesion to be a heavily calcified right coronary artery disease.Interventions:After an initial unsuccessful PCI attempt due to a balloon uncrossable lesion in the right coronary artery, the patient underwent a complex RA-PCI.Outcomes:The procedure was complicated by the Kokeshi phenomenon, where the rota-burr became stuck in the calcified lesion, and coronary artery perforation occurred. Through innovative management, including the use of covered stents, both complications were successfully resolved, and the patient was discharged in stable condition.Lessons:This case highlights the challenges and potential complications in treating heavily calcified coronary lesions with RA-PCI. Successful management requires prompt identification and innovative solutions to mitigate risks and improve outcomes. The patient’s condition was stabilized, and the procedure was successful, with full resolution of complications and normalization of cardiac function postprocedure.

IntroductionThe increasing incidence of coronary heart disease, driven by socio-economic development and population aging, poses significant challenges. Coronary calcification, a major factor complicating percutaneous coronary interventions (PCI), often necessitates rotational atherectomy (RA) for lesion preparation. However, the impact of different RA rotational speeds on procedural and clinical outcomes remains unclear. While low-speed RA (LSRA) has been suggested to reduce intraoperative slow flow, evidence is inconsistent, and the benefits of combining LSRA with high-speed RA (HSRA) are not well established. This study aims to evaluate the effectiveness of different rotational speed protocols to guide clinical practice.Methods and analysisThis single-center, randomized controlled trial will target patients with severe coronary artery calcification scheduled for RA. An estimated 210 patients will be enrolled based on sample size calculation, randomly assigned in a 1:1:1 ratio to different rotational speed protocols using a random number table. These will include a continuous low-speed rotation (LSRA) group (140,000 rpm), a continuous high-speed rotation (HSRA) group (180,000 rpm), and a high-speed to low-speed rotation (HSRA + LSRA) group (initially 180,000 rpm, followed by 100,000 rpm). The primary endpoint is the incidence of complications during RA, including coronary artery spasm, slow/no reflow, dissection, burr entrapment, guidewire fracture, and perforation. Secondary outcomes encompass intravascular imaging (IVUS or OCT) assessments (detecting calcific ring disruption and measuring the target lesion’s minimum lumen area (MLA) and minimum lumen diameter (MLD)); in-hospital cardiac death, acute stent thrombosis, and heart failure occurrences; and the 1-year incidence of major adverse cardiovascular and cerebrovascular events (MACCE).DiscussionThe RACE study evaluates the impact of different rotational speeds in coronary rotational atherectomy, aiming to provide guidance for clinical practice. The findings may help standardize RA procedures and inform future clinical guidelines, improving procedural consistency and patient outcomes.Registration numberChiCTR2300076194. Registered on September 27, 2023.

TCTAP C-158 Distal Coronary Artery Perforation Management, Case Report

Combined left main coronary artery (LMCA) lesion and chronic coronary artery occlusion (CTO) significantly worsens the clinical course of patients with CHD, affecting the prognosis and complicating interventional treatment of this category of patients. Aim. To analyze the effectiveness and technical features of interventional procedures in patients with ischemic heart disease and left coronary artery lesion combined with CTO of one of the coronary arteries. Materials and methods. We included 30 patients with combined LMCA stenotic lesion and CTO of one of the main coronary arteries in the study. The average age of the patients was 62.4±9.7 years, 90% were men. Clinical manifestations were characterized by anginal syndrome of varying severity: 25 (83.3%) patients had CCS III, 23.3% of patients had diabetes mellitus, 19 (63.3%) patients had a history of MI in the area of the occluded artery, and the ejection fraction (EF) was 52.8±11.3%. Results. The lesion of the LCA was combined with the RCA CTO in 9 cases (30%). Occlusion of the CX and stenosis of the LM were recorded in 10 cases (33%). In 11 cases, combined lesion of the LCA and the LAD was recorded (37%). The technical success of CTO recanalization in the group was 86.6%. In 17 cases, stenting of the LM was performed before CTO intervention and stenting of the LM after CTO intervention in 10 cases. CTO recanalization without stenting of the LM was performed in 3 cases. The intervention beam time was 42.4±22.3 min, and the air rudder index was 1887.1±948.4 mGy. The main technique of CTO recanalization used in our series of patients was the AWE (antegrade wire escalation) technique. Retrograde access was used in 3 (10%) cases. No operative mortality was recorded. In one case, coronary artery perforation occurred. Conclusions. In patients with combined lesions of the LCA and CTO, where CABG is of high risk or not feasible, interventional approach can be successfully used. The priority of performing the intervention on the LCA or CTO depends on the anatomy of the coronary artery lesions and clinical manifestations of the disease.

Coronary artery perforation (CAP) is one of the most serious complications of percutaneous coronary intervention. Coronary arteriovenous fistula is a considerably rare type of congenital CAP. They are usually difficult to distinguish. A male patient developed coronary artery perforation during percutaneous coronary intervention. As balloon occlusion was ineffective, a decision was made to implant a spring coil and bypass the occluded segment. However, the placement of spring coils restored patency in the occluded distal segment of the right coronary artery (RCA). Coronary computed tomography angiography is an auxiliary tool and Digital Subtraction Angiography(DSA) is the gold standard for the diagnosis. Surgery and implant a spring coil are the main treatment methods. The patient's RCA regained its blood supply. Coronary artery recanalization arteries occurred after spring coil placement. Combined with the imaging presentation, we finally determined that he was coronary-right ventricular fistula. Although congenital CAPs are rare, appropriate detection and timely confirmation by coronary angiography are important for determining their subsequent management. Congenital coronary arteriovenous fistulae may be considered when coronary artery perforation during percutaneous coronary intervention, balloon blockade is ineffective and the patient's vital signs are stable.

Percutaneous Coronary Interventions (PCI) are widely performed procedures in modern cardiology but carry risks, including vessel perforation. This report describes two cases of Left Main Coronary Artery (LMCA) perforation managed with stentgraft implantation

The incidence of coronary artery perforations after stenting is 0.1—0.71%. Subsequent coronary artery bypass grafting for the treatment of complication is described in a few reports. This approach is characterized by high mortality due to cardiac tamponade and perioperative myocardial infarction. In this case, the patient underwent coronary artery bypass grafting of 3 coronary arteries. Thrombosis of venous graft to obtuse marginal artery occurred within several hours after surgery. This required percutaneous coronary intervention with stenting. However, coronary artery perforation near anastomosis with venous graft occurred immediately after stenting. In this article, we present successful emergency stentectomy followed by coronary artery bypass grafting of obtuse marginal artery.

New-generation single-layer polytetrafluorethylene (PTFE-) or polyurethane (PU-) covered stent (CS) for the treatment of coronary artery perforation (CAP) during PCI offer high procedural efficacy. To evaluate the comparative long-term safety and efficacy of both devices. This is a multicenter pooled analysis of individual data of patients with CAP undergoing implantation of single-layer PTFE-CS or PU-CS. Procedural endpoint was strategy success defined as successful placement of CS and sealing of perforation without surgical conversion. Clinical endpoints were mortality, myocardial infarction (MI), target vessel revascularization (TVR) and definite or probable stent thrombosis (def/prob ST) at 12 months. Seventy patients with CAP underwent implantation of two hundred eight CS, ninety-two PTFE-CS, and one hundred sixteen PU-CS. More than 1 stent was implanted in 13 patients (17.1%) in PTFE-CS group and 19 patients (20.2%) in PU-CS group, P = 0.80. Strategy success was high (96.1% versus 92.5%., P = 0.62). At 12 months, 71 patients (93.2%) in PTFE-CS group versus 79 patients (81%) in the PU-CS were alive, P = 0.05; TVR occurred in 14 patients (28.4%) in PTFE-CS group and 12 patients (17.9%) in PU-CS group, P= 0.54; MI in 1 patient (1.3%) in PTFE-CS group and 1 patients (1.1%) in PU-CS group, P = 0.86. Rates of def/prob ST were comparable 1.3% in PTFE-CS versus 3.1% in PU-CS P = 0.95. A strategy of implantation of a new-generation single-layer PTFE- or PU-CS for the treatment of coronary artery perforation showed high success rates. Both new-generation CS showed favorable and similar clinical safety, in particular with regard to thrombotic events.Graphical abstract

Abstract Coronary artery perforation (CAP) is a rare but life-threatening complication of percutaneous coronary intervention (PCI), requiring early recognition and management. With the availability of new and better hardware and the use of new techniques, interventionalists tend to attempt complex lesions, which may increase the risk of this dreadful complication. We present a series of six cases of CAP and their management.

Introduction and Objectives: Coronary artery perforation (CAP) is a rare but potentially fatal complication of percutaneous coronary intervention (PCI). Although its management is well‐studied in tertiary care settings, little is known about the incidence and treatment patterns at district general hospitals (DGHs), which this study explored.Materials and Methods: A single‐centre analysis of all PCI procedures in a DGH between January 2011 and December 2023 was performed. Patients’ records were examined for procedure details and endpoints, which included pericardiocentesis, emergency cardiac surgery and secondary coronary artery bypass grafting. The endpoints also included in‐hospital and one‐year mortalities.Results: During the study period, there were 13,480 PCIs, of which 31 (0.23%) were complicated by CAP. Males composed 65%, and the mean age was 69.9 ± 10 years. The most common perforation type was Ellis II in 45% of patients, and the left anterior ascending artery (LAD) was most affected in 55% of patients. An echocardiogram was done in all patients and showed tamponade physiology in 16%, in all of whom pericardiocentesis was performed. Other CAP treatments included balloon tamponade in 65%, covered stent in 42%, fat embolisation in 10% and emergency surgery and coiling in 6% each. Inpatient mortality occurred in three patients (10%), with no one‐year mortalities. Long‐term complications were not observed in the study.Conclusion: CAP remains a rare, potentially lethal complication of PCI in a DGH setting, with an incidence, pattern and treatments similar to those of high‐volume PCI teaching centres. Early recognition and proper management are crucial.