Delayed abrupt tamponade by isolated left atrial compression following coronary artery perforation during coronary angioplasty.

Cardiac tamponade following coronary artery perforation during percutaneous coronary intervention is a rare but potentially life-threatening complication. When associated with Ellis type III coronary perforations, tamponade develops rapidly during the intervention. In contrast, Ellis type I and II coronary perforations, because of their contained nature, are usually managed conservatively and rarely result in tamponade. We report two unusual cases of delayed but abrupt tamponade caused by localized left atrial compression after contained coronary artery perforation following angioplasty. This complication is an extremely rare event. Etiology, diagnostic modalities, and management are discussed.     

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.     

Incidence, correlates, management, and clinical outcome of coronary perforation: analysis of 16,298 procedures

Background

Coronary perforation is a serious but uncommon complication of percutaneous coronary intervention (PCI) and is associated with significant morbidity and mortality.

Methods

We performed an analysis of the Mayo Clinic PCI database. Clinical records, procedural reports, and angiographic studies were reviewed. Multiple logistic regression analysis was performed to identify clinical, procedural, anatomic, and angiographic correlates of coronary perforation.

Results

A total of 16,298 PCI procedures were performed between January 1990 and December 2001. We identified 95 coronary perforations (0.58%; 95% CI, 0.47-0.71). The incidence of coronary perforation varied with time. Correlates of coronary perforation included the use of an atheroablative device and female sex. Twelve patients (12.6%) sustained an acute myocardial infarction, and cardiac tamponade developed in 11 patients (11.6%). Management strategies included reversal of heparin, pericardiocentesis, placement of a covered stent, and surgical repair. Seven patients died (7.4%).

Conclusions

Coronary perforation during PCI is rare, but is associated with significant morbidity and mortality. The variable frequency of perforation may be explained by temporal variations in the use of atheroablative devices.     

经皮冠状动脉介入治疗并发心包积液及心脏压塞的临床分析

目的 了解经皮冠状动脉介入治疗(PCI)中心包积液／心脏压塞发生率、发生的相关因素、处理以及预后，为PCI的正确操作及合理选用器械提供参考。方法 分析了1246例PCI资料，包括住院病历、PCI操作记录、护理记录和影像学资料，判定心包积液／心脏压塞发生原因、时间、临床表现、处理方式和结果。结果 共8例心包积液(0．64％)、3例心脏压塞(0．24％)，其中10例(91％)在导管室确诊，1例(9％)延期发现。冠状动脉造影直接发现导引钢丝和／或球囊致冠状动脉穿孔9例(81．8％)，其中球囊通过冠状动脉破口未扩张2例，球囊通过冠状动脉破口并扩张1例，冠状动脉穿孔多发生在慢性完全闭塞性病变(CTO)；通过临床表现、超声心动图证实起搏电极导线致右心室穿孔2例(18．2％)，均出现在心肌梗死后患者。球囊通过冠状动脉破口并扩张1例，发生迟发性心脏压塞，6h后急诊外科干预引流后治愈；右心室临时起搏电极导管穿破右心室2例，1例行心包穿刺术，另1例心包穿刺后留置猪尾导管引流2d成功治愈。结论 冠状动脉及右心室穿孔是PCI并发心包积液／心脏压塞的主要原因，前者多发生在CTO患者，后者易出现于心肌梗死后患者。正确的操作方法及合理的器械选择可能减少此并发症的发生。冠状动脉穿孔较心室穿孔易于诊断，心包积液／心脏压塞多数能在导管室早期发现，并能得以合理的处理。     

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。     

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.     

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.     

Coronary artery perforation: How to treat it?

Coronary artery perforation fortunately represents a rare complication of coronary catheterization but, if not properly and promptly treated, it is burdened by a high mortality rate. Rates of coronary perforation may be potentially higher when atherectomy devices are used or very complex calcified lesions are treated. Cardiac tamponade constitutes the most severe clinical consequence.We report the case of an intra-stent coronary perforation at the end of revascularization of a non-ST elevation myocardial infarction (NSTEMI), followed by an immediate impairment of hemodynamic compensation, due to significant pericardial effusion and subsequent cardiac tamponade.The use of covered stents has revolutionized the management of coronary perforation and this has meant that the use of emergency CABG has decreased over the years with satisfactory immediate and short-term outcomes, reducing the incidence of acute cardiac tamponade and mortality without surgery.     

心脏介入治疗并发心脏压塞的临床分析

目的:总结心脏介入治疗并发心脏压塞的临床特点、诊断、治疗和结果。方法:分析1998年1月~2005年6月进行心脏介入治疗发生心脏压塞的12例患者资料。结果:12例患者发生心脏压塞,其中起搏器置入术2例,射频消融术2例,冠心病介入治疗术3例,房间隔缺损封堵术1例,上腔静脉滤器置入术1例,冠状动脉瘘造影1例,肥厚型心肌病行NOGA标测1例,心包穿刺引流术1例。早发心脏压塞6例,迟发心脏压塞6例;早发心脏压塞多表现为术中血压、心率突然下降,透视下心影外缘出现透亮环,心脏搏动减弱;迟发心脏压塞患者可表现为血压下降、心率增快、休克。救治成功10例,死亡2例。结论:强化诊断意识、早期识别心脏压塞、及时行心包穿刺引流、外科处理是抢救的关键。     

Compression of right ventricular out-flow due to localized hematoma after coronary perforation during PCI.

Although coronary perforation can cause tamponade during percutaneous coronary intervention (PCI), this is unusual for patients previously undergoing coronary artery bypass graft surgery (CABG) due to pericardial adhesions. We report here on a rare case of right ventricular out-flow obstruction complicating PCI in a patient with a previous CABG.     

Management and outcomes of coronary artery perforation during percutaneous coronary intervention

Coronary perforation is a particularly feared complication of percutaneous coronary intervention. The optimal management and predictors of adverse outcomes for these patients remain to be defined. Advances in management such as the use of polytetrafluoroethylene-covered stents have not been critically examined in terms of efficacy. We analyzed a cohort of patients who sustained coronary perforation during percutaneous coronary intervention at our institution during a 9-year period to examine the trends in incidence, management, and outcomes. The patient medical records were reviewed, and detailed angiographic analysis was undertaken to identify the predictors of adverse outcomes, including the development of tamponade, the requirement for emergency coronary artery bypass grafting, and in-hospital death. One year of follow-up was attempted for all patients. Seventy-two cases of coronary perforation were identified, with an overall incidence of 0.19%. The perforation grade and presence of chronic renal insufficiency were the only predictors of mortality on multivariate regression analysis. The use of polytetrafluoroethylene-covered stents to manage perforations was not associated with any reduction in adverse outcomes, such as the development of tamponade, the need for emergency coronary artery bypass grafting, or in-hospital death. In conclusion, coronary perforation remains a feared complication in the contemporary interventional era with significant in-hospital mortality. Emphasis should be placed on preventing this complication whenever possible, including exercising particular caution in patients with chronic renal insufficiency. The treatment of such patients should be tailored to the severity of the perforation. The optimal treatment of these patients needs to be defined, and the efficacy of covered stents needs to be studied prospectively.     

Complete left atrial obliteration due to localized tamponade after coronary artery perforation during PTCA

Coronary artery perforation is a rare but important complication of percutaneous revascularization (PTCA). Clinical events following coronary perforation may include cardiac tamponade. After bypass graft operation (CABG), however, cardiac tamponade with subsequent hemodynamic instability is unusual due to the development of pericardial adhesions. We report an unusual case of localized tamponade after coronary artery perforation during PTCA in a patient with previous CABG. Cathet. Cardiovasc. Diagn. 45:61–63, 1998. © 1998 Wiley-Liss, Inc.     

冠状动脉介入治疗并发冠状动脉穿孔及心脏压塞的处理对策

目的　探讨冠状动脉介入治疗 (PCI)中并发冠状动脉穿孔及心脏压塞的处理对策。方法　对我院 1989年 9月至 2 0 0 3年 9月期间发生的冠状动脉穿孔病例进行回顾性分析。结果　共完成经皮腔内冠状动脉成形术 (PTCA)及支架 72 32例。发生冠状动脉穿孔 18例 ,发生率为 0 2 5 % ,多数发生于慢性完全闭塞性病变 (83 3% ) ,其中引导钢丝所致穿孔者 9例 ,球囊扩张后穿孔 7例 ,置入支架后穿孔 2例。 14例 (77 8% )穿孔为少量对比剂排至心包腔内或心肌内 ,其中 7例用球囊长时间低压力贴附封堵破口 ,穿孔征象消失 ;6例用鱼精蛋白静脉注射中和肝素 ,1例未做特殊处理 ,穿孔消失。4 (2 2 2 % )例发生急性心脏压塞 ,超声心动图显示有心包积液 ,紧急心包穿刺引流后病情平稳。 2例外科急诊修补血管破口 ,同时行冠状动脉旁路移植术 (CABG)。无一例死亡。结论　PCI并发冠状动脉穿孔少见 ,及时发现和正确处理是避免严重并发症的关键。     

Repair of saphenous vein perforation with covered stent during angioplastic

Coronary perforation or rupture is an infrequent complication of angioplasty which may have a poor prognosis and influence patient survival. Cardiac tamponade or the presence of ischemia leading to acute myocardial infarction may require emergency cardiac surgery. Surgical treatment of perforation or rupture of the coronary arteries is based on prolonged inflation with angioplasty balloons or autoperfusion. There are few studies on the placement of covered stents to seal the perforation. We present the case of a patient who presented saphenous vein graft rupture following high pressure stent implantation requiring percutaneous placement of a covered stent.     

Failed pericardiocentesis for acute cardiac tamponade: Two cases associated with bivalirudin administration during PCI

Successful management of acute cardiac tamponade secondary to coronary artery perforation during percutaneous coronary intervention (PCI) includes sealing off the site of perforation and pericardiocentesis. We report two cases of acute cardiac tamponade during PCI associated with the administration of bivalirudin, in which attempts at percutaneous pericardiocentesis failed, due to the present of thrombus, rather blood, in the pericardium. © 2009 Wiley‐Liss, Inc.     

The changing pattern of coronary perforation during percutaneous coronary intervention in the new device era

We report the incidence, management and clinical outcome of coronary perforations in 39 of 12,658 patients (0.3%) undergoing percutaneous coronary intervention (PCI). Coronary perforation occurred more frequently with debulking techniques than with non-debulking (percutaneous transluminal coronary angioplasty and stent) techniques (1% versus 0.2%; p<0.001). There were 8 type I (20.5%), 15 type II (38.5%) and 16 type III (41%) perforations. Importantly, fifty-one percent of the coronary perforations were guide-wire related. Major adverse clinical outcomes occurred more frequently in patients who experienced type III perforations. Conventional strategies to treat perforations (i.e., prolonged balloon inflation and reverse of the anticoagulated state) were used. There was one death (2.6%), two emergency surgeries (5.2%) and no Q-wave myocardial infarctions. Pericardial effusion occurred in 18 of 39 patients (46.2%), with cardiac tamponade occurring in 7 patients. In the current device era, the incidence of coronary perforation remains low; it occurs more frequently with debulking devices and is often a consequence of guidewire injury. Its outcome is not affected with the use of IIb/IIIa antagonists. Treatment of coronary perforation requires early detection, angiographic classification, immediate occlusion of coronary vessel extravasation and relief of hemodynamic compromise, reversal of heparin anticoagulation, platelet transfusion in those patients treated with abciximab and cover stents.     

Superior vena cava syndrome: a rare complication of saphenous vein graft stenting: a case report

Rupture of coronary artery bypass graft during percutaneous coronary intervention is a rare but serious complication. These perforations are often associated with myocardial infarction, pericardial tamponade, immediate or delayed, emergency bypass surgery and even death. We report an interesting case where perforation of a saphenous vein graft occurred after direct stenting, resulting in a very rare complication of superior vena cava (SVC) syndrome.     

Recurrent cardiac tamponade following unusual micro leak after successful closure of the primary leak

Although uncommon, coronary artery perforation is one of the most dreadful complications of percutaneous coronary intervention, which requires prompt, aggressive, and effective management. Perforations induced by coronary guidewires are usually located in the distal part of a coronary artery and commonly managed with embolization. This is an unusual case report of guidewire-induced coronary perforation with recurrent cardiac tamponade, which was managed successfully by coil embolization of both ipsilateral and contralateral coronary arteries via transradial approach.     

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.