Advertisement

Incidence, Treatment, and Outcomes of Coronary Perforation During Chronic Total Occlusion Percutaneous Coronary Intervention

      Coronary perforation is a potential complication of chronic total occlusion (CTO) percutaneous coronary intervention (PCI). We analyzed 2,097 CTO PCIs performed in 2,049 patients from 2012 to 2017. Patient age was 65 ± 10 years, 85% were men, and 36% had prior coronary artery bypass graft surgery. Technical and procedural success were 88% and 87%, respectively. A major periprocedural adverse cardiovascular event occurred in 2.6%. Coronary perforation occurred in 85 patients (4.1%); The frequency of Ellis class 1, 2, and 3 perforations was 21%, 26%, and 52%, respectively. Perforation occurred more frequently in older patients and those with previous coronary artery bypass graft surgery (61% vs 35%, p < 0.001). Cases with perforation were angiographically more complex (Multicenter CTO Registry in Japan score 3.0 ± 1.2 vs 2.5 ± 1.3, p < 0.001). Twelve patients (14%) with perforation experienced tamponade requiring pericardiocentesis. Patient age, previous PCI, right coronary artery target CTO, blunt or no stump, use of antegrade dissection re-entry, and the retrograde approach were associated with perforation. Adjusted odds ratio for periprocedural major periprocedural adverse cardiovascular events among patients with perforation was 15.04 (95% confidence interval 7.35 to 30.18). In conclusion, perforation occurs relatively infrequently in contemporary CTO PCI performed by experienced operators and is associated with baseline patient characteristics and angiographic complexity necessitating use of advanced crossing techniques. In most cases, perforations do not result in tamponade requiring pericardiocentesis, but they are associated with reduced technical and procedural success, higher periprocedural major adverse events, and reduced procedural efficiency.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to American Journal of Cardiology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Rossello X.
        • Pujadas S.
        • Serra A.
        • Bajo E.
        • Carreras F.
        • Barros A.
        • Cinca J.
        • Pons-Llado G.
        • Vaquerizo B.
        Assessment of inducible myocardial ischemia, quality of life, and functional status after successful percutaneous revascularization in patients with chronic total coronary occlusion.
        Am J Cardiol. 2016; 117: 720-726
        • Bruckel J.T.
        • Jaffer F.A.
        • O'Brien C.
        • Stone L.
        • Pomerantsev E.
        • Yeh R.W.
        Angina severity, depression, and response to percutaneous revascularization in patients with chronic total occlusion of coronary arteries.
        J Invasive Cardiol. 2016; 28: 44-51
        • Kirschbaum S.W.
        • Baks T.
        • van den Ent M.
        • Sianos G.
        • Krestin G.P.
        • Serruys P.W.
        • de Feyter P.J.
        • van Geuns R.J.
        Evaluation of left ventricular function three years after percutaneous recanalization of chronic total coronary occlusions.
        Am J Cardiol. 2008; 101: 179-185
        • Jones D.A.
        • Weerackody R.
        • Rathod K.
        • Behar J.
        • Gallagher S.
        • Knight C.J.
        • Kapur A.
        • Jain A.K.
        • Rothman M.T.
        • Thompson C.A.
        • Mathur A.
        • Wragg A.
        • Smith E.J.
        Successful recanalization of chronic total occlusions is associated with improved long-term survival.
        JACC Cardiovasc Interv. 2012; 5: 380-388
        • Brilakis E.S.
        • Banerjee S.
        • Karmpaliotis D.
        • Lombardi W.L.
        • Tsai T.T.
        • Shunk K.A.
        • Kennedy K.F.
        • Spertus J.A.
        • Holmes Jr, D.R.
        • Grantham J.A.
        Procedural outcomes of chronic total occlusion percutaneous coronary intervention: a report from the NCDR (National Cardiovascular Data Registry).
        JACC Cardiovasc Interv. 2015; 8: 245-253
        • Kinnaird T.
        • Kwok C.S.
        • Kontopantelis E.
        • Ossei-Gerning N.
        • Ludman P.
        • deBelder M.
        • Anderson R.
        • Mamas M.A.
        • British Cardiovascular Intervention S and the National Institute for Cardiovascular Outcomes R
        Incidence, determinants, and outcomes of coronary perforation during percutaneous coronary intervention in the United Kingdom between 2006 and 2013: an analysis of 527 121 cases from the British Cardiovascular Intervention Society Database.
        Circ Cardiovasc Interv. 2016; 9 (pii: e003449)
        • Parsh J.
        • Seth M.
        • Green J.
        • Sutton N.R.
        • Chetcuti S.
        • Dixon S.
        • Grossman P.M.
        • Khandelwal A.
        • Dupree J.M.
        • Gurm H.S.
        Coronary artery perforations after contemporary percutaneous coronary interventions: evaluation of incidence, risk factors, outcomes, and predictors of mortality.
        Catheter Cardiovasc Interv. 2017; 89: 966-973
        • Danek B.A.
        • Karatasakis A.
        • Karmpaliotis D.
        • Alaswad K.
        • Yeh R.W.
        • Jaffer F.A.
        • Patel M.P.
        • Mahmud E.
        • Lombardi W.L.
        • Wyman M.R.
        • Grantham J.A.
        • Doing A.
        • Kandzari D.E.
        • Lembo N.J.
        • Garcia S.
        • Toma C.
        • Moses J.W.
        • Kirtane A.J.
        • Parikh M.A.
        • Ali Z.A.
        • Karacsonyi J.
        • Rangan B.V.
        • Thompson C.A.
        • Banerjee S.
        • Brilakis E.S.
        Development and validation of a scoring system for predicting periprocedural complications during percutaneous coronary interventions of chronic total occlusions: the Prospective Global Registry for the Study of Chronic Total Occlusion Intervention (PROGRESS-CTO) Complications Score.
        J Am Heart Assoc. 2016; 5 (pii: e004272)
        • Karmpaliotis D.
        • Karatasakis A.
        • Alaswad K.
        • Jaffer F.A.
        • Yeh R.W.
        • Wyman R.M.
        • Lombardi W.L.
        • Grantham J.A.
        • Kandzari D.E.
        • Lembo N.J.
        • Doing A.
        • Patel M.
        • Bahadorani J.N.
        • Moses J.W.
        • Kirtane A.J.
        • Parikh M.
        • Ali Z.A.
        • Kalra S.
        • Nguyen-Trong P.K.
        • Danek B.A.
        • Karacsonyi J.
        • Rangan B.V.
        • Roesle M.K.
        • Thompson C.A.
        • Banerjee S.
        • Brilakis E.S.
        Outcomes with the use of the retrograde approach for coronary chronic total occlusion interventions in a contemporary multicenter US Registry.
        Circ Cardiovasc Interv. 2016; 9 (pii: e003434)
        • Danek B.A.
        • Karatasakis A.
        • Karmpaliotis D.
        • Alaswad K.
        • Yeh R.W.
        • Jaffer F.A.
        • Patel M.
        • Bahadorani J.
        • Lombardi W.L.
        • Wyman M.R.
        • Grantham J.A.
        • Doing A.
        • Moses J.W.
        • Kirtane A.
        • Parikh M.
        • Ali Z.A.
        • Kalra S.
        • Kandzari D.E.
        • Lembo N.
        • Garcia S.
        • Rangan B.V.
        • Thompson C.A.
        • Banerjee S.
        • Brilakis E.S.
        Use of antegrade dissection re-entry in coronary chronic total occlusion percutaneous coronary intervention in a contemporary multicenter registry.
        Int J Cardiol. 2016; 214: 428-437
        • Kiernan T.J.
        • Yan B.P.
        • Ruggiero N.
        • Eisenberg J.D.
        • Bernal J.
        • Cubeddu R.J.
        • Witzke C.
        • Don C.
        • Cruz-Gonzalez I.
        • Rosenfield K.
        • Pomersantev E.
        • Palacios I.
        Coronary artery perforations in the contemporary interventional era.
        J Interv Cardiol. 2009; 22: 350-353
        • Hendry C.
        • Fraser D.
        • Eichhofer J.
        • Mamas M.A.
        • Fath-Ordoubadi F.
        • El-Omar M.
        • Williams P.
        Coronary perforation in the drug-eluting stent era:incidence, risk factors, management and outcome: the UK experience.
        EuroIntervention. 2012; 8: 79-86
        • Al-Lamee R.
        • Ielasi A.
        • Latib A.
        • Godino C.
        • Ferraro M.
        • Mussardo M.
        • Arioli F.
        • Carlino M.
        • Montorfano M.
        • Chieffo A.
        • Colombo A.
        Incidence, predictors, management, immediate and long-term outcomes following grade III coronary perforation.
        JACC Cardiovasc Interv. 2011; 4: 87-95
        • Ellis S.G.
        • Ajluni S.
        • Arnold A.Z.
        • Popma J.J.
        • Bittl J.A.
        • Eigler N.L.
        • Cowley M.J.
        • Raymond R.E.
        • Safian R.D.
        • Whitlow P.L.
        Increased coronary perforation in the new device era. Incidence, classification, management, and outcome.
        Circulation. 1994; 90: 2725-2730
        • Thygesen K.
        • Alpert J.S.
        • Jaffe A.S.
        • Simoons M.L.
        • Chaitman B.R.
        • White H.D.
        • Thygesen K.
        • Alpert J.S.
        • White H.D.
        • Biomarker S.
        • Jaffe A.S.
        • Katus H.A.
        • Apple F.S.
        • Lindahl B.
        • Morrow D.A.
        • Chaitman B.R.
        • Clemmensen P.M.
        • Johanson P.
        • Hod H.
        • Imaging S.
        • Underwood R.
        • Bax J.J.
        • Bonow J.J.
        • Pinto F.
        • Gibbons R.J.
        • Fox K.A.
        • Atar D.
        • Newby L.K.
        • Galvani M.
        • Hamm C.W.
        • Uretsky B.F.
        • Steg P.G.
        • Wijns W.
        • Bassand J.P.
        • Menasche P.
        • Ravkilde J.
        • Ohman E.M.
        • Antman E.M.
        • Wallentin L.C.
        • Armstrong P.W.
        • Simoons M.L.
        • Januzzi J.L.
        • Nieminen M.S.
        • Gheorghiade M.
        • Filippatos G.
        • Luepker R.V.
        • Fortmann S.P.
        • Rosamond W.D.
        • Levy D.
        • Wood D.
        • Smith S.C.
        • Hu D.
        • Lopez-Sendon J.L.
        • Robertson R.M.
        • Weaver D.
        • Tendera M.
        • Bove A.A.
        • Parkhomenko A.N.
        • Vasilieva E.J.
        • Mendis S.
        • Bax J.J.
        • Baumgartner H.
        • Ceconi C.
        • Dean V.
        • Deaton C.
        • Fagard R.
        • Funck-Brentano C.
        • Hasdai D.
        • Hoes A.
        • Kirchhof P.
        • Knuuti J.
        • Kolh P.
        • McDonagh T.
        • Moulin C.
        • Popescu B.A.
        • Reiner Z.
        • Sechtem U.
        • Sirnes P.A.
        • Tendera M.
        • Torbicki A.
        • Vahanian A.
        • Windecker S.
        • Morais J.
        • Aguiar C.
        • Almahmeed W.
        • Arnar D.O.
        • Barili F.
        • Bloch K.D.
        • Bolger A.F.
        • Botker H.E.
        • Bozkurt B.
        • Bugiardini R.
        • Cannon C.
        • de Lemos J.
        • Eberli F.R.
        • Escobar E.
        • Hlatky M.
        • James S.
        • Kern K.B.
        • Moliterno D.J.
        • Mueller C.
        • Neskovic A.N.
        • Pieske B.M.
        • Schulman S.P.
        • Storey R.F.
        • Taubert K.A.
        • Vranckx P.
        • Wagner D.R.
        • Joint ESCAAHAWHFTFfUDoMI
        • Authors/Task Force Members C
        • Subcommittee ECG
        • Classification S
        • Intervention S
        • Trials, Registries S
        • Trials, Registries S
        • Trials, Registries S
        • Trials, Registries S
        • Guidelines ESCCfP
        • Document R
        Third universal definition of myocardial infarction.
        J Am Coll Cardiol. 2012; 60: 1581-1598
        • Morino Y.
        • Abe M.
        • Morimoto T.
        • Kimura T.
        • Hayashi Y.
        • Muramatsu T.
        • Ochiai M.
        • Noguchi Y.
        • Kato K.
        • Shibata Y.
        • Hiasa Y.
        • Doi O.
        • Yamashita T.
        • Hinohara T.
        • Tanaka H.
        • Mitsudo K.
        • Investigators J.C.R.
        Predicting successful guidewire crossing through chronic total occlusion of native coronary lesions within 30 minutes: the J-CTO (Multicenter CTO Registry in Japan) score as a difficulty grading and time assessment tool.
        JACC Cardiovasc Interv. 2011; 4: 213-221
        • Christopoulos G.
        • Kandzari D.E.
        • Yeh R.W.
        • Jaffer F.A.
        • Karmpaliotis D.
        • Wyman M.R.
        • Alaswad K.
        • Lombardi W.
        • Grantham J.A.
        • Moses J.
        • Christakopoulos G.
        • Tarar M.N.
        • Rangan B.V.
        • Lembo N.
        • Garcia S.
        • Cipher D.
        • Thompson C.A.
        • Banerjee S.
        • Brilakis E.S.
        Development and validation of a novel scoring system for predicting technical success of chronic total occlusion percutaneous coronary interventions: the PROGRESS-CTO (Prospective Global Registry for the Study of Chronic Total Occlusion Intervention) Score.
        JACC Cardiovasc Interv. 2016; 9: 1-9
        • Patel V.G.
        • Brayton K.M.
        • Tamayo A.
        • Mogabgab O.
        • Michael T.T.
        • Lo N.
        • Alomar M.
        • Shorrock D.
        • Cipher D.
        • Abdullah S.
        • Banerjee S.
        • Brilakis E.S.
        Angiographic success and procedural complications in patients undergoing percutaneous coronary chronic total occlusion interventions: a weighted meta-analysis of 18,061 patients from 65 studies.
        JACC Cardiovasc Interv. 2013; 6: 128-136
        • El Sabbagh A.
        • Patel V.G.
        • Jeroudi O.M.
        • Michael T.T.
        • Alomar M.E.
        • Mogabgab O.
        • Fuh E.
        • Roesle M.
        • Rangan B.V.
        • Abdullah S.
        • Hastings J.L.
        • Grodin J.
        • Kumbhani D.J.
        • Alexopoulos D.
        • Fasseas P.
        • Banerjee S.
        • Brilakis E.S.
        Angiographic success and procedural complications in patients undergoing retrograde percutaneous coronary chronic total occlusion interventions: a weighted meta-analysis of 3,482 patients from 26 studies.
        Int J Cardiol. 2014; 174: 243-248
        • Shimony A.
        • Zahger D.
        • Van Straten M.
        • Shalev A.
        • Gilutz H.
        • Ilia R.
        • Cafri C.
        Incidence, risk factors, management and outcomes of coronary artery perforation during percutaneous coronary intervention.
        Am J Cardiol. 2009; 104: 1674-1677
        • Fasseas P.
        • Orford J.L.
        • Panetta C.J.
        • Bell M.R.
        • Denktas A.E.
        • Lennon R.J.
        • Holmes D.R.
        • Berger P.B.
        Incidence, correlates, management, and clinical outcome of coronary perforation: analysis of 16,298 procedures.
        Am Heart J. 2004; 147: 140-145
        • Gruberg L.
        • Pinnow E.
        • Flood R.
        • Bonnet Y.
        • Tebeica M.
        • Waksman R.
        • Satler L.F.
        • Pichard A.D.
        • Kent K.M.
        • Leon M.B.
        • Lindsay Jr, J.
        Incidence, management, and outcome of coronary artery perforation during percutaneous coronary intervention.
        Am J Cardiol. 2000; 86 (A8): 680-682
        • Sharma V.
        • Wilson W.
        • Smith W.
        • McEntegart M.
        • Oldroyd K.
        • Sidik N.
        • Bagnall A.
        • Egred M.
        • Irving J.
        • Strange J.
        • Johnson T.
        • Walsh S.
        • Hanratty C.
        • Spratt J.
        Comparison of characteristics and complications in men versus women undergoing chronic total occlusion percutaneous intervention.
        Am J Cardiol. 2017; 119: 535-541
        • Tarar M.N.
        • Christakopoulos G.
        • Brilakis E.S.
        Successful management of a distal vessel perforation through a single 8-French guide catheter: combining balloon inflation for bleeding control with coil embolization.
        Catheter Cardiovasc Interv. 2015; 86: 412-416
        • Kotsia A.P.
        • Brilakis E.S.
        • Karmpaliotis D.
        Thrombin injection for sealing epicardial collateral perforation during chronic total occlusion percutaneous coronary interventions.
        J Invasive Cardiol. 2014; 26: E124-E126
        • Shemisa K.
        • Karatasakis A.
        • Brilakis E.S.
        Management of guidewire-induced distal coronary perforation using autologous fat particles versus coil embolization.
        Catheter Cardiovasc Interv. 2017; 89: 253-258
        • Sandoval Y.
        • Lobo A.S.
        • Brilakis E.S.
        Covered stent implantation through a single 8-french guide catheter for the management of a distal coronary perforation.
        Catheter Cardiovasc Interv. 2017; (Epub ahead of print)https://doi.org/10.1002/ccd.27020
        • Karatasakis A.
        • Akhtar Y.N.
        • Brilakis E.S.
        Distal coronary perforation in patients with prior coronary artery bypass graft surgery: the importance of early treatment.
        Cardiovasc Revasc Med. 2016; 17: 412-417
        • Tavano D.
        • Carlino M.
        • Pisani M.
        • Colombo A.
        Images in cardiovascular medicine. Conservative treatment of a left atrial hematoma and a localized tamponade occurring during treatment of coronary total occlusion.
        Circulation. 2007; 115: e603-e606
        • Stathopoulos I.
        • Kossidas K.
        • Panagopoulos G.
        • Garratt K.
        Cardiac tamponade complicating coronary perforation during angioplasty: short-term outcomes and long-term survival.
        J Invasive Cardiol. 2013; 25: 486-491