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| {{SI}}
| | #redirect:[[PCI complications: vessel perforation]] |
| {{WikiDoc Cardiology Network Infobox}}
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| {{CMG}}<br/>
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| '''Associate Editors-In-Chief:''' Xin Yang, M.D.; Duane Pinto, M.D.; Brian C. Bigelow, M.D.
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| ==Background==
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| Coronary perforation occurs when a [[dissection]] or an [[intimal]] tear is so severe that it extends outward sufficiently to completely penetrate the arterial wall. It is an uncommon complication of [[PCI|coronary intervention]], with an incidence of 0.19%-0.58%<ref name="pmid16996872">{{cite journal |author=Javaid A, Buch AN, Satler LF, ''et al.'' |title=Management and outcomes of coronary artery perforation during percutaneous coronary intervention |journal=Am. J. Cardiol. |volume=98 |issue=7 |pages=911–4 |year=2006 |month=October |pmid=16996872 |doi=10.1016/j.amjcard.2006.04.032 |url=}}</ref><ref name="pmid14691432">{{cite journal |author=Fasseas P, Orford JL, Panetta CJ, ''et al.'' |title=Incidence, correlates, management, and clinical outcome of coronary perforation: analysis of 16,298 procedures |journal=Am. Heart J. |volume=147 |issue=1 |pages=140–5 |year=2004 |month=January |pmid=14691432 |doi= |url=}}</ref><ref name="pmid11246236">{{cite journal |author=Dippel EJ, Kereiakes DJ, Tramuta DA, ''et al.'' |title=Coronary perforation during percutaneous coronary intervention in the era of abciximab platelet glycoprotein IIb/IIIa blockade: an algorithm for percutaneous management |journal=Catheter Cardiovasc Interv |volume=52 |issue=3 |pages=279–86 |year=2001 |month=March |pmid=11246236 |doi=10.1002/ccd.1065 |url=}}</ref>, as noted among various studies. However, it is associated with significant [[morbidity]] and mortality. One study found a 12.6% incidence of [[acute myocardial infarction]], 11.6% incidence of [[cardiac tamponade]] and a mortality rate of 7.4%<ref name="pmid14691432">{{cite journal |author=Fasseas P, Orford JL, Panetta CJ, ''et al.'' |title=Incidence, correlates, management, and clinical outcome of coronary perforation: analysis of 16,298 procedures |journal=Am. Heart J. |volume=147 |issue=1 |pages=140–5 |year=2004 |month=January |pmid=14691432 |doi= |url=}}</ref>.
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| Associations with coronary perforation include:
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| * Balloon to artery ratio > 1.1
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| * Use of debulking procedure
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| * Complex coronary anatomy (i.e. [[calcified]] lesion, [[chronic total occlusion]], [[tortuosity]] of the vessel and ostial lesion)
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| * Stiff and [[hydrophilic]] wires
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| ==Classification==
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| The Ellis Classification<ref name="pmid7994814">{{cite journal |author=Ellis SG, Ajluni S, Arnold AZ, ''et al.'' |title=Increased coronary perforation in the new device era. Incidence, classification, management, and outcome |journal=Circulation |volume=90 |issue=6 |pages=2725–30 |year=1994 |month=December |pmid=7994814 |doi= |url=}}</ref> categorizes coronary artery perforations based on their angiographic appearance in the following manner:
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| * '''Type I''' - Extraluminal crater without [[extravasation]]
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| * '''Type II''' - [[Epicardial]] fat or myocardial blush without contrast jet extravasation
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| * '''Type III''' - Extravasation through frank (> 1 mm) perforation
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| * '''Type III "cavity spilling" (CS)''' - Refers to Type III perforations with contrast spilling directly into either the [[left ventricle]], [[coronary sinus]] or other anatomic circulatory chamber
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| The Ellis Classification was evaluated as a predictor of certain outcomes and as a basis for management. Stratifying the outcomes by perforation type are summarized as follows<ref name="pmid7994814">{{cite journal |author=Ellis SG, Ajluni S, Arnold AZ, ''et al.'' |title=Increased coronary perforation in the new device era. Incidence, classification, management, and outcome |journal=Circulation |volume=90 |issue=6 |pages=2725–30 |year=1994 |month=December |pmid=7994814 |doi= |url=}}</ref>:
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| * '''Type I''' - No deaths or [[myocardial infarction]], [[tamponade]] incidence 8%
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| * '''Type II''' - No deaths, [[myocardial infarction]] incidence 14%, [[tamponade]] incidence 13%
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| * '''Type III''' - Mortality incidence 19%, cardiac [[tamponade]] incidence 63%, the need for urgent [[bypass surgery]] 63%
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| * '''Type III "cavity spilling" (CS)''' - No deaths, [[myocardial infarction]] or [[tamponade]], but sample limited in size
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| ==Goals of Treatment==
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| There are several goals involved in treating perforations. Prevention of complications such as [[tamponade]], [[MI|myocardial infarction (MI)]] and death is critical. It is important to maintain [[hemodynamic]] stability. Should tamponade occur, it is important to detect and treat it immediately. Additionally, a goal of treatment is to decrease the need for emergent [[bypass surgery]].
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| ==Treatment==
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| Many different treatment options exist. First, the reversal of [[anticoatulation]] can be accomplished with [[Protamine]] if the patient is on [[heparin]] (guided by activated clotting time), or through [[platelet]] [[transfusions]] (4-10 units) if the patient was given [[abciximab]] or [[thienopyridine]]. Prolonged balloon inflation may be another treatment option. Immediate occlusion of the perforated vessel at the perforation site for 10 minutes at 2-4 [[atms]]. If there is continued evidence of perforation, use perfusion balloons if available to allow for prolonged inflation without inducing myocardial [[ischemia]].
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| ==References==
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| {{reflist}}
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| {{SIB}}
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| [[Category:Cardiology]]
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