Coronary Artery Perforation
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Associate Editors-In-Chief: Xin Yang, M.D.; Duane Pinto, M.D.; Brian C. Bigelow, M.D.
Background
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 coronary intervention, with an incidence of 0.19%-0.58%[1][2][3], 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%[2].
Associations with coronary perforation include:
- Balloon to artery ratio > 1.1
- Use of debulking procedure
- Complex coronary anatomy (i.e. calcified lesion, chronic total occlusion, tortuosity of the vessel and ostial lesion)
- Stiff and hydrophilic wires
Classification
The Ellis Classification[4] categorizes coronary artery perforations based on their angiographic appearance in the following manner:
- Type I - Extraluminal crater without extravasation
- Type II - Epicardial fat or myocardial blush without contrast jet extravasation
- Type III - Extravasation through frank (> 1 mm) perforation
- 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
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[4]:
- Type I - No deaths or myocardial infarction, tamponade incidence 8%
- Type II - No deaths, myocardial infarction incidence 14%, tamponade incidence 13%
- Type III - Mortality incidence 19%, cardiac tamponade incidence 63%, the need for urgent bypass surgery 63%
- Type III "cavity spilling" (CS) - No deaths, myocardial infarction or tamponade, but sample limited in size
Goals of Treatment
There are several goals involved in treating perforations. Prevention of complications such as tamponade, 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.
Treatment
Many different treatment options exist. Depending on the severity of the perforation, up to 90% can be treated successfully without surgery.
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.
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.
Other measures can be considered after prolong balloon inflation is initiated. Coil embolization and intra aortic balloon pump (IABP) counterpulsation are two options.
Additionally, polytetrafluoroethylene (PTFE) covered stents (Jomed stent)[5] 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.
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.
Urgent echocardiography is an option to evaluate for pericardial effusion and tamponade physiology. Immediate notification of the cardiothoracic surgical team is important.
Advantages of Each Choice
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.
PTFE coated stent placement can rapidly and effectively close vessel wall defects, obviating open surgical procedures.
Surgical repair offers the advantage of visualizing difficult-to-identify perforations. Cardiopulmonary bypass may be needed to hemodynamically stabilize patients with perforations.
Coil embolization is suitable for small side branch perforations, but it will lead to tissue infarction and may not be available in all catheterization laboratories.
Making a Selection
Initial management of perforations should always begin with prolonged balloon inflation.
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.
Coil embolization is suited for small vessels, distal locations, arteries that supply limited viable myocardium, or situations where surgery is contraindicated.
Surgical closure is necessary for perforations that demonstrate continued bleeding despite minimal invasive therapy, refractory ischemia, or recurrent hemorrhage.
Pericardiocentesis is indicated to prevent overt cardiac tamponade for all patients who accumulate pericardial fluid as evidenced by increasing right atrial pressure.
Is Treatment Working?
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.
Serial echocardiography should be performed q 6-12h.
References
- ↑ Javaid A, Buch AN, Satler LF; et al. (2006). "Management and outcomes of coronary artery perforation during percutaneous coronary intervention". Am. J. Cardiol. 98 (7): 911–4. doi:10.1016/j.amjcard.2006.04.032. PMID 16996872. Unknown parameter
|month=ignored (help) - ↑ 2.0 2.1 Fasseas P, Orford JL, Panetta CJ; et al. (2004). "Incidence, correlates, management, and clinical outcome of coronary perforation: analysis of 16,298 procedures". Am. Heart J. 147 (1): 140–5. PMID 14691432. Unknown parameter
|month=ignored (help) - ↑ Dippel EJ, Kereiakes DJ, Tramuta DA; et al. (2001). "Coronary perforation during percutaneous coronary intervention in the era of abciximab platelet glycoprotein IIb/IIIa blockade: an algorithm for percutaneous management". Catheter Cardiovasc Interv. 52 (3): 279–86. doi:10.1002/ccd.1065. PMID 11246236. Unknown parameter
|month=ignored (help) - ↑ 4.0 4.1 Ellis SG, Ajluni S, Arnold AZ; et al. (1994). "Increased coronary perforation in the new device era. Incidence, classification, management, and outcome". Circulation. 90 (6): 2725–30. PMID 7994814. Unknown parameter
|month=ignored (help) - ↑ Fineschi M, Gori T, Sinicropi G, Bravi A (2004). "Polytetrafluoroethylene (PTFE) covered stents for the treatment of coronary artery aneurysms". Heart. 90 (5): 490. PMC 1768192. PMID 15084537. Unknown parameter
|month=ignored (help)