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| {{SI}}
| | #redirect:[[PCI complications: vessel perforation]] |
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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 another anatomic circulatory chamber
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| The Ellis Classification was evaluated as a predictor of certain outcomes and as a basis for management. Stratification of the outcomes by perforation type is 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. Depending on the severity of the perforation, up to 90% can be treated successfully without surgery.
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| The reversal of [[anticoagulation]] 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]].
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| 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]] is recommended. 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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| Other measures can be considered after prolong balloon inflation is initiated. Coil [[embolization]] and [[IABP|intra aortic balloon pump (IABP)]] counterpulsation are two options.
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| Additionally, [[polytetrafluoroethylene|polytetrafluoroethylene (PTFE)]] covered stents (Jomed stent)<ref name="pmid15084537">{{cite journal |author=Fineschi M, Gori T, Sinicropi G, Bravi A |title=Polytetrafluoroethylene (PTFE) covered stents for the treatment of coronary artery aneurysms |journal=Heart |volume=90 |issue=5 |pages=490 |year=2004 |month=May |pmid=15084537 |pmc=1768192 |doi= |url=}}</ref> can seal the perforation site. However, the stent is bulky and can be difficult to deploy. To decrease the timing between deflation of balloon and deployment of the stent, bilateral [[groin]] access with the two guide catheters approach should be considered.
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| Adjunctive hemodynamic monitoring and support is another option for treatment. Hemodynamic assessment with right heart pressure monitoring should be considered, but it is important to pay particular attention to a sudden rise in right [[atrial]] filling pressures. Also, it is important to monitor heart borders on [[fluoroscopy]] to detect signs of [[tamponade]], as signified by a lack of movement of the heart borders.
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| Urgent [[echocardiography]] is an option to evaluate for [[pericardial effusion]] and [[tamponade]] [[physiology]]. Immediate notification of the [[Cardiac surgery|cardiothoracic surgical]] team is important.
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| ==Advantages of Each Choice==
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| Prolonged balloon inflations can be performed rapidly. However, patients may not tolerate balloon inflations because of the development of [[ischemia]], [[arrhythmias]], or [[hemodynamic]] instability. Therefore, perfusion balloon use may be optimal if it is available.
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| [[PTFE]] coated stent placement can rapidly and effectively close vessel wall defects, obviating open surgical procedures.
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| Surgical repair offers the advantage of visualizing difficult-to-identify perforations. [[Cardiopulmonary bypass]] may be needed to [[hemodynamically]] stabilize patients with perforations.
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| Coil [[embolization]] is suitable for small side branch perforations, but it will lead to tissue infarction and may not be available in all [[Cath lab|catheterization laboratories]].
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| ==Making a Selection==
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| Initial management of perforations should always begin with prolonged balloon inflation.
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| Once prolonged balloon inflation is attempted, other options may be explored. [[PTFE]] coated stents have now become more readily available and are deployed more frequently. They can be used for most coronary perforations, but small, excessively angulated or [[tortuous]] vessels may not be amenable to them.
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| Coil [[embolization]] is suited for small vessels, distal locations, arteries that supply limited viable [[myocardium]], or situations where surgery is [[contraindicated]].
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| Surgical closure is necessary for perforations that demonstrate continued bleeding despite minimal invasive therapy, refractory [[ischemia]], or recurrent [[hemorrhage]].
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| [[Pericardiocentesis]] is indicated to prevent overt cardiac [[tamponade]] for all patients who accumulate [[pericardial]] fluid as evidenced by increasing right atrial pressure.
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| ==Is Treatment Working?==
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| There are several signs that indicate whether treatment is failing. Incomplete closure is signified by persistent dye extravasation, while [[pericardial]] fluid collection and impending cardiac [[tamponade]] is signified by increasing right atrial pressure. Peristent fluid accumulation or pericardial drain output (>24 h) should prompt surgical repair.
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| Serial echocardiography should be performed q 6-12h.
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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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