Management of Coronary Artery Perforation

Coronary artery perforation (CAP) is a rare but potentially life-threatening complication of percutaneous coronary intervention (PCI), however if recognized and managed promptly, its adverse consequences can be minimized. Risk factors for CAP include the use of advanced PCI technique (such as atherectomy and chronic total occlusion interventions) and treatment of severely calcified lesions. There are 3 major types of CAP depending on location: (a) large vessel perforation, (b) distal vessel perforation, and (c) collateral perforation.Large vessel perforation is usually treated with implantation of a covered stent, whereas distal and collateral vessel perforations are usually treated with coil or fat embolization. In this article we provide a state-of-the-art overview of the contemporary management of CAP.     

Ellis type 4 coronary artery perforation during percutaneous coronary intervention: Case series and review

Ellis type 4 coronary artery perforation (CAP4), also referred to as Ellis type 3 cavity-spilling perforation, is a rare but life-threatening complication of percutaneous coronary intervention characterized by extravasation of blood into a cardiac chamber, anatomic cavity, or coronary sinus or vessel. CAP4 is uncommon, accounting for 1.9% to 3.0% of all CAP. Only 11 cases of CAP4 have been reported in detail; we report an additional two cases and review prior reports of this rare complication. Our first case highlights a patient with chronic anginal symptoms due to a 75% concentric stenotic lesion in the mid-LAD. Revascularization was complicated by perforation during pre-dilation with robust contrast extravasation into the left ventricle. Successful postperforation hemostasis was achieved with heparin reversal and covered stent placement. The second case demonstrates another major mechanism of CAP4: wire perforation. During intervention, the absence of blood flow distal to the lesion in the setting of an ST segment elevation myocardial infarction obscured the course of the nonhydrophilic floppy wire leading to perforation that was managed conservatively. In our scoping review, we found that the majority of CAP4 occurred in the LAD. The most frequently involved cavity was the left ventricle—other cavities involved were the right ventricle and coronary veins. Common etiologies of CAP4 included guidewire perforation (62%) and balloon dilation (31%). Perforation was managed with reversal of anticoagulation in 46% of cases, prolonged balloon inflation in 54% of cases, and covered stent deployment in 15% of cases. No patients required surgical repair or pericardiocentesis and perforations were successfully sealed in all cases. In-hospital mortality was 0%.     

Novel economic treatment for coronary wire perforation: A case report

BACKGROUNDCoronary artery perforation is a rare but potentially life-threatening complication of percutaneous coronary intervention (PCI), however if recognized and managed promptly, its adverse consequences can be minimized. Risk factors include the use of advanced PCI technique (such as atherectomy and chronic total occlusion interventions) and treatment of severely calcified lesions. Large vessel perforation is usually treated with implantation of a covered stent, whereas distal and collateral vessel perforations are usually treated with embolization of coils, fat, thrombin, or collagen. We describe a novel and cost-effective method of embolisation using a cut remnant of a used angioplasty balloon that was successful in sealing a distal wire perforation. we advocate this method as a simple method of managing distal vessel perforation.CASE SUMMARYA 73-year-old male with previous coronary Bypass graft operation and recurrent angina on minimal exertion had undergone rotablation and PCI to his dominant left circumflex. At the end of the procedure there was evidence of wire perforation at the distal branch and despite prolonged balloon tamponade there continued to be extravasation and the decision was made to seal this perforation. A cut piece of an angioplasty balloon was used and delivered on the original angioplasty wire to before the perforation area and released which resulted in sealing of the perforation with no unwanted clinical consequences.CONCLUSIONThe use of a balloon remnant for embolization in coronary perforation presents a simple, efficient and cost-effective method for managing coronary perforations and may be an alternative for achieving hemostasis and preventing poor outcome. Prevention remains the most important part with meticulous attention to the distal wire position, particularly with hydrophilic wires.     

Novel approach to coronary artery perforation repair

Coronary artery perforation (CAP) during percutaneous coronary intervention is a rare but serious complication. Treatment options of CAP include prolonged balloon inflation, covered stent, and coil embolization. Although most cases of CAP can be treated with prolonged balloon inflation, some cases, especially Ellis grade III CAP require covered stents or coiling. Covered stents may require a large bore guide catheter and have a high rate of restenosis, which can be a limiting factor in patients with severe peripheral arterial disease. Coil embolization is generally used in distal CAP because coiling in the proximal vessels results in a large territory of infarction. We present a case of an Ellis grade III CAP during rotational atherectomy successfully treated with a novel coiling technique whereby the thrombogenic coil extends through the perforation outside of the vessel, and the intraarterial portion of the coil is excluded from the lumen by drug‐eluting stent placement over the proximal portion of the coil.     

ST-elevation myocardial infarction caused by coronary artery compression due to localized pericardial hematoma caused by coronary perforation

Coronary perforation is a rare but serious complication of percutaneous coronary intervention (PCI). We report a case of coronary perforation during PCI in a post cardiac surgery patient presenting as unusual ST-segment elevation myocardial infarction, secondary to compression of an epicardial artery by a localized hematoma, secondary to coronary perforation by the guidewire.     

Delayed and recurrent cardiac tamponade following distal coronary perforation of hydrphilic guidewires during coronary intervention

Coronary artery perforation is a rare complication of percutaneous coronary intervention, but can result in cardiac tamponade and is thus potentially life-threatening. It is well recognized that the use of hydrophilic wires during interventional procedures increases the risk of coronary perforation. We report two cases in which a particular looping configuration was suspected of causing vessel laceration with subsequent development of pericardial effusion and tamponade. In one case, tamponade occurred several days after the index procedure, mimicking acute myocardial infarction. In the second case, tamponade was successfully treated with immediate pericardial drainage, but tamponade recurred several days later.     

Cardiac perforation complicated by cardiac tamponade and sealed with metallic coils

Distal coronary artery perforation with an angioplasty guidewire is a rare complication that may cause cardiac tamponade, myocardial infarction, arrhythmia, and even death. The use of platelet IIb/IIIa glycoprotein receptor inhibitors increases the risk of potentially fatal complications that are difficult to manage. We report a patient on treatment with abciximab who presented coronary perforation in a distal branch of the right coronary artery caused by the coronary guidewire tip, and complicated by acute cardiac tamponade. Blood extravasation to the pericardium was stopped by releasing two metallic coils into the distal vessel, thereby avoiding the need for emergent cardiac surgery.     

冠状动脉血栓性病变早期和延迟介入治疗的疗效观察

目的　探讨冠状动脉内血栓形成对介入治疗早期疗效的影响。方法　自 1995年 10月至 2 0 0 2年 3月我院共对 115例有冠状动脉内血栓形成的患者进行了介入治疗 ,其中 4 8例即刻行冠状动脉介入治疗 (即刻治疗组 ) ,其他患者在肝素或溶栓治疗 7d后行介入治疗 (延迟治疗组 )。结果即刻治疗组和延迟治疗组的手术成功率相似 (91 7%比 97 1% ,P >0 0 5 ) ,但冠状动脉急性闭塞和严重心脏不良事件的发生例数即刻治疗组明显高于延迟治疗组 (3例比 0例和 2 7例比 16例 ,P值均 <0 0 5 )。结论　当冠状动脉内存在血栓形成时 ,在适时肝素治疗后行冠状动脉介入治疗可明显降低严重心脏不良事件的发生率。     

10例冠状动脉穿孔患者置入带膜支架后的长期随访研究

目的评价带膜支架治疗经皮冠状动脉介入治疗(percutaneous coronary intervention,PCI)术中发生冠状动脉穿孔患者的长期疗效。方法从2004年6月至2012年6月,本中心共对10例PCI中发生冠状动脉穿孔后置入带膜支架的患者进行了随访,观察其主要心脏不良事件(major adverse cardiac events,MACE)发生率。置入带膜支架术后服用氯吡格雷75mg/d共2年,长期服用肠溶阿司匹林100mg/d。结果 10例患者中男性6例,女性4例;年龄(68.6±5.2)岁,范围60～76岁。置入带膜支架直径平均(3.3±0.3)mm,长度平均(22.1±3.7)mm,所有患者破口均被成功封闭,术中无死亡病例。随访时间(31.7±24.5)个月,范围0.6～67个月,1例术后19天因肺部感染导致多器官功能衰竭而死亡,1例术后13个月猝死;1例患者术后53个月出现心绞痛;1例术后6个月查多层CT示支架内无再狭窄;4例患者复查冠状动脉造影,只有1例患者在PCI术后67个月复查冠状动脉造影示左前降支(LAD)带膜支架内再狭窄;另3例病例带膜支架内均无再狭窄。住院期间死亡率为10%(1/10);PCI术后12个月,MACE发生率为10%(1/10);在整个随访期间靶血管再狭窄率为20%(1/5),死亡率为20%(2/10),MACE发生率为40%(4/10)。结论带膜支架治疗冠状动脉穿孔能达到较好的长期疗效,两年的双联抗血小板药物可能能有效预防带膜支架内血栓形成。     

Percutaneous coronary intervention in anticoagulated patients via radial artery access

Objectives: To assess safety and feasibility of using radial artery access for percutaneous coronary intervention (PCI) in patients on oral anticoagulation without interrupting therapy. Background: The radial artery approach for PCI is intuitively attractive for patients receiving chronic oral anticoagulation with vitamin K antagonists (VKAs) but little data exist concerning feasibility or safety of this approach in this population. The main advantage of this strategy would be to avoid bridging therapy with heparin that increases risk of thrombotic and bleeding events. Methods: In this prospective observational study, 50 consecutive patients referred for coronary angiography underwent PCI without interrupting oral anticoagulant therapy. The main outcome measures were bleeding and thrombotic complications. Results: The indications for permanent oral anticoagulation were as follows: atrial fibrillation in 62%, mechanical prosthesis in 24%, and venous thromboembolism in 14%. Seventy‐two percent were elective cases and 28% presented with acute coronary syndromes. PCI was performed with an INR range of 1.4–3.4 with mean of 2.2 ± 0.6. Seventy‐six percent of the patients were on dual antiplatelet therapy before the procedure. No thrombotic events or excess bleeding were observed at 1 month. Only one patient had a minor hemorrhage 8 days after procedure. Conclusions: This series suggests that for patients treated with VKAs, the use of radial artery access is feasible and safe for PCI on dual antiplatelet therapy without interrupting oral anticoagulant treatment. © 2008 Wiley‐Liss, Inc.     

Coronary perforation during percutaneous coronary intervention

Coronary perforation is an undesirable complication during percutaneous coronary intervention (PCI). We reviewed the cases of overt coronary perforation in our institute and analyzed their clinical backgrounds, the characteristics of the target lesion, management, and clinical outcomes. Between 1991 and 2005, we experienced 12 cases (0.35%) of coronary perforation in a total of 3415 PCI procedures. The perforation occurred during the use of debulking devices in 3 cases, immediately after stenting in 2, immediately after postdilatation of the stent in 2, and during wiring in 3 cases. Restoration was attempted by long inflation of a balloon in 7 cases, implantation of a covered stent graft in 1, and emergency surgical repair in 1 case. Subsequent cardiac tamponade occurred in 3 patients who required pericardiocentesis, and 1 patient died due to congestive heart failure. Administration of protamine was effective in stopping the bleeding in 6 patients, whereas continuation of antiplatelet therapy resulted in no overt rebleeding. Coronary perforation during PCI is a rare complication but is associated with significant morbidity and mortality. Intravenous administration of protamine is effective when it is used in conjunction with nonsurgical devices for initial management of perforation.     

Successful utilization of a novel aspiration thrombectomy catheter (Pronto) for the treatment of patients with stent thrombosis.

Stent thrombosis is a rare but catastrophic complication of percutaneous coronary intervention (PCI). Thrombolytic therapy is ineffective for the treatment of patients with stent thrombosis, while primary PCI in such patients is limited by a high thrombus burden in the culprit vessel often leading to distal embolization and extensive tissue infarction. We present three patients with stent thrombosis successfully treated with the adjunctive use of a novel and new aspiration thrombectomy device (Pronto).     

冠心病患者介入治疗失败后行急诊冠状动脉旁路移植术的预后

目的 探讨冠心病患者经皮冠状动脉介入治疗失败后行急诊冠状动脉旁路移植术(CABG)的预后.方法回顾性分析2002年1月至2010年12月阜外心血管病医院11例经皮冠状动脉介入治疗失败后行急诊CABG患者的临床资料,并进行随访.院内随访内容包括心脏性死亡、Q波心肌梗死、肾功能不全、神经系统事件;院外随访的研究终点为主要心血管不良事件,包括死亡、心肌梗死和靶病变血管重建.结果 患者年龄(61±5)岁.冠状动脉造影显示三支病变患者5例(45.5％).在介入治疗的靶血管病变中,9例(81.8％)位于左前降支,中、重度钙化、慢性完全闭塞及弥漫性长病变分别为3例(27.3％)、4例(36.4％)和4例(36.4％).11例患者均有行急诊CABG的指征,其中冠状动脉夹层5例(45.5％)、冠状动脉穿孔 3例(27.3％)、病变无法充分扩张1例(9.1％)、血管急性闭塞1例(9.1％)和支架脱载1例(9.1％).CABG术后随访(47±33)个月.院内随访期间,发生心脏性死亡1例(9.1％),Q波心肌梗死2例(18.2％).院外随访期间,1例(9.1％)患者死于肾功能衰竭,无因心原性事件再次住院的患者.结论经皮冠状动脉介入治疗失败后行急诊CABG多见于复杂冠状动脉病变,术后患者的长期预后良好.     

冠心病介入治疗1 501例并发症分析--单中心16年资料

目的　总结分析我院心内科冠状动脉介入治疗 (PCI)的并发症发生率、发生原因和防治措施。方法　应用回顾性调查的方法对在本院心内科于 1988年 10月至 2 0 0 3年 12月冠心病介入治疗的主要并发症类型、发生率及其年度分布特征进行统计分析 ,并进一步分析与严重并发症发生有关的危险因素。结果　共 15 0 1例进行PCI;总的并发症发生率 5 5 3% ;主要并发症有住院期间死亡(0 5 9% )、急诊CABG(0 13% )、非致死性Q波心肌梗死 (0 13% )、冠状动脉穿孔 (0 2 0 % )、球囊破裂(0 2 0 % )、支架脱落 (0 13% )、冠状动脉痉挛 (1 87% )、急性闭塞 (1 5 3% )、无复流 (0 73% )、心室颤动(0 33% )、左主干夹层 (0 13% )、急性左心功能不全 (0 2 6 % )等。单纯球囊扩张患者急性闭塞和冠状动脉痉挛发生率高 ,支架置入后明显降低 (分别由 4 4 1%和 2 4 8%降至 1 0 5 %和 1 2 3% ) ;冠状动脉介入治疗严重并发症的主要危险因素是急性心肌梗死时急诊介入治疗。结论　随着经验的积累 ,介入治疗并发症的发生率降低 ,但仍应引起介入医师重视。     

Left main coronary thrombosis: unusual complication after radiofrequency ablation of left accessory atrioventricular pathway

Radiofrequency ablation (RFA) has established itself as a first-line therapy for the curative treatment of many patients with supraventricular or atrioventricular tachycardias and has exhibited a generally low incidence of serious sequelae (N Engl J Med. 1991;324:1612; Lancet. 1991;337:1557). Coronary artery injury is a rare complication. We present a patient with an acute thrombotic total occlusion of the left main coronary artery immediately after the end of RFA who was successfully treated with emergency percutaneous transluminal coronary angioplasty. This case illustrates an unusual coronary complication of RFA and serves as an exceptional example of survival with a good short-term prognosis after this unusual etiology of myocardial infarction.     

Early and late clinical outcomes following coronary perforation in patients undergoing percutaneous coronary intervention.

Coronary perforation is a rare but serious complication that occurs during percutaneous coronary intervention (PCI). This study examines the frequency of coronary perforation during PCI, evaluates the management strategies used to treat perforations, and describes the long-term prognosis of patients who have developed coronary perforation during PCI. Coronary perforations were found in 69 (0.93%) of 7,443 consecutive PCI procedures, occurring more often after use of a new device (0.86%) than after use of balloon angioplasty (0.41%) (p<0.05). Coronary perforation was attributable solely to the coronary guidewire in 27 (0.36%) cases. Coronary perforations were divided into 2 types: (1) Those with epicardial staining without ajet of contrast extravasation (type I, n=51), and (2) those with a jet of contrast extravasation (type II, n= 18). Patients with type I and type II perforations were managed by observation only (35% and 0%, respectively), reversal of anticoagulation (57% and 94%), pericardiocentesis and drainage (27% and 61%), and prolonged perfusion balloon angioplasty (16% and 100%). Two patients with type II perforations required emergency coronary artery bypass surgery. There were no in-hospital deaths. Late pseudoaneurysms developed in 18 (28.6%) patients during the 13.4 +/- 11.3 months' follow-up period, and were more common in patients with type II perforations (72.2% vs 11.1% with type I perforations; p<0.001). During the follow-up period, no patient had evidence of coronary rupture. The results suggest that coronary perforation is uncommon after PCI, and can be managed without cardiac surgery in the majority of cases. Late pseudoaneurysms developed in some patients, particularly in patients with type II perforations, but there were no late consequences of coronary perforation after PCI.     

A cholesterol embolism following coronary angioplasty. A case report

Cholesterol embolism is a rare but serious complication of heart catheterization. We report a patient in whom cholesterol embolization syndrome developed after coronary angioplasty complicated by an acute myocardial infarction which was treated with streptokinase and heparin. The clinical outcome was satisfactory. Cholesterol embolism occurrence might have been precipitated in this patient by thrombolytic and anticoagulant therapy.     

Delayed spontaneous recanalization of a totally occluded right coronary artery following failed percutaneous coronary intervention with associated Type F dissection: case report and review

Coronary artery dissection is a well-known and frequent complication of percutaneous coronary intervention (PCI). We report the first case of a Type F dissection following PCI of the distal right coronary artery causing total vessel occlusion that could not be stented but was associated with late spontaneous recanalization and a favorable outcome.     

Acute and long-term outcome after coronary artery perforation during percutaneous coronary interventions

BACKGROUND: Coronary artery perforation is a rare but serious complication of percutaneous coronary interventions (PCI). METHODS: 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. RESULTS: 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. CONCLUSION: 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.     

经皮冠状动脉介入治疗并发冠状动脉穿孔25例分析

目的 探讨经皮冠状动脉介入治疗（PCI）并发冠状动脉穿孔的处理策略。方法纳入2004年5月至2010年10月行PCI治疗并发冠状动脉穿孔的25例患者,对患者的临床资料进行回顾性分析,根据穿孔的影像特征进行Ellis分型,对各型冠状动脉穿孔的处理策略进行分析与总结。结果冠状动脉穿孔的发生率为0.82%（25/2036）,其中Ⅰ型穿孔13例（52%）,Ⅱ型穿孔3例（12%）,Ⅲ型穿孔9例（36%）,死亡2例（8%）。Ⅰ型穿孔患者采取严密观察,但未行特殊处理。Ⅱ型穿孔患者予以停用抗凝药物,球囊长时间低压扩张,其中1例于术后24h出现心包填塞,心包穿刺引流后病情逐渐稳定。Ⅲ型穿孔患者4例经球囊低压力贴附封堵穿孔部位后破口消失,3例行带膜支架置入,2例在球囊长时间低压力贴附封堵穿孔部位同时使用鱼精蛋白,但使用鱼精蛋白后均出现冠状动脉内慢血流死亡;Ⅲ型穿孔患者中4例出现急性心包填塞。结论冠状动脉穿孔发生率低,但可导致严重临床后果,及时正确处理是减少恶性心脏事件的关键。