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

      Coronary artery perforation is a feared complication of chronic total occlusion (CTO) percutaneous coronary intervention (PCI). Our objective was to describe the incidence, mechanisms, treatment, and outcomes of coronary artery perforation during CTO PCI. We analyzed the baseline clinical and angiographic characteristics and procedural outcomes of 10,454 CTO PCIs performed in 10,219 patients between 2012 and 2022. The incidence of coronary perforation was 4.9% (n = 503). Patients who experienced coronary perforation were older and were more likely to have had previous coronary artery bypass graft surgery. Procedures that resulted in perforation were more complex, with higher Japanese CTO and Prospective Global Registry for the Study of Chronic Total Occlusion Intervention (PROGRESS-CTO) scores. Technical (66% vs 87%, p <0.001) and procedural (55% vs 87%, p <0.001) success rates were lower in perforation cases. The CTO target vessel was the most common perforation site (66%). The retrograde approach was responsible for the perforation in 47% of cases, and guidewire exit was the most common perforation mechanism. The proportion of Ellis class 1, 2, 3, and 3 -“cavity spilling” coronary perforations was 20%, 41%, 28%, and 11%, respectively. In 52% of perforations, 1 or more interventions were required: prolonged balloon inflation (23%), covered stent deployment (21%), coil embolization (6%), and/or autologous fat embolization (4%). Tamponade requiring pericardiocentesis occurred in 69 patients (14%). The incidence of major adverse cardiovascular events was higher in perforation cases (18% vs 1.3%, p <0.001). In conclusion, coronary artery perforation occurred in 4.9% of CTO PCIs performed by experienced operators and was associated with lower technical success and higher in-hospital major adverse cardiovascular events.
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      References

        • Moroni F
        • Brilakis ES
        • Azzalini L.
        Chronic total occlusion percutaneous coronary intervention: managing perforation complications.
        Expert Rev Cardiovasc Ther. 2021; 19: 71-87
        • Azzalini L
        • Karmpaliotis D
        • Santiago R
        • Mashayekhi K
        • Di Mario C
        • Rinfret S
        • Nicholson WJ
        • Carlino M
        • Yamane M
        • Tsuchikane E
        • Brilakis ES.
        Contemporary issues in chronic total occlusion percutaneous coronary intervention.
        JACC Cardiovasc Interv. 2022; 15: 1-21
        • Riley RF
        • Sapontis J
        • Kirtane AJ
        • Karmpaliotis D
        • Kalra S
        • Jones PG
        • Lombardi WL
        • Grantham JA
        • McCabe JM.
        Prevalence, predictors, and health status implications of periprocedural complications during coronary chronic total occlusion angioplasty.
        EuroIntervention. 2018; 14: e1199-e1206
        • Shaukat A
        • Tajti P
        • Sandoval Y
        • Stanberry L
        • Garberich R
        • Nicholas Burke M
        • Gössl M
        • Henry T
        • Mooney M
        • Sorajja P
        • Traverse J
        • Bradley SM
        • Brilakis ES
        Incidence, predictors, management and outcomes of coronary perforations.
        Catheter Cardiovasc Interv. 2019; 93: 48-56
        • Lemmert ME
        • van Bommel RJ
        • Diletti R
        • Wilschut JM
        • de Jaegere PP
        • Zijlstra F
        • Daemen J
        • Van Mieghem NM.
        Clinical characteristics and management of coronary artery perforations: a single-center 11-year experience and practical overview.
        J Am Heart Assoc. 2017; 6e007049
        • Karmpaliotis D
        • Karatasakis A
        • Alaswad K
        • Jaffer FA
        • Yeh RW
        • Wyman RM
        • Lombardi WL
        • Grantham JA
        • Kandzari DE
        • Lembo NJ
        • Doing A
        • Patel M
        • Bahadorani JN
        • Moses JW
        • Kirtane AJ
        • Parikh M
        • Ali ZA
        • Kalra S
        • Nguyen-Trong PK
        • Danek BA
        • Karacsonyi J
        • Rangan BV
        • Roesle MK
        • Thompson CA
        • Banerjee S
        • Brilakis ES.
        Outcomes With the use of the retrograde approach for coronary chronic total occlusion interventions in a contemporary multicenter US registry.
        Circ Cardiovasc Interv. 2016; 9e003434
        • Danek BA
        • Karatasakis A
        • Karmpaliotis D
        • Alaswad K
        • Yeh RW
        • Jaffer FA
        • Patel M
        • Bahadorani J
        • Lombardi WL
        • Wyman MR
        • Grantham JA
        • Doing A
        • Moses JW
        • Kirtane A
        • Parikh M
        • Ali ZA
        • Kalra S
        • Kandzari DE
        • Lembo N
        • Garcia S
        • Rangan BV
        • Thompson CA
        • Banerjee S
        • Brilakis ES.
        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
        • Parsh J
        • Seth M
        • Green J
        • Sutton NR
        • Chetcuti S
        • Dixon S
        • Grossman PM
        • Khandelwal A
        • Dupree JM
        • Gurm HS.
        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
        • Harris PA
        • Taylor R
        • Minor BL
        • Elliott V
        • Fernandez M
        • O'Neal L
        • McLeod L
        • Delacqua G
        • Delacqua F
        • Kirby J
        • Duda SN
        • Consortium REDCap
        The REDCap consortium: building an international community of software platform partners.
        J Biomed Inform. 2019; 95103208
        • Harris PA
        • Taylor R
        • Thielke R
        • Payne J
        • Gonzalez N
        • Conde JG.
        Research Electronic Data Capture (REDCap)–a metadata-driven methodology and workflow process for providing translational research informatics support.
        J Biomed Inform. 2009; 42: 377-381
        • 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
        • Registry Investigators J-CTO
        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 DE
        • Yeh RW
        • Jaffer FA
        • Karmpaliotis D
        • Wyman MR
        • Alaswad K
        • Lombardi W
        • Grantham JA
        • Moses J
        • Christakopoulos G
        • Tarar MNJ
        • Rangan BV
        • Lembo N
        • Garcia S
        • Cipher D
        • Thompson CA
        • Banerjee S
        • Brilakis ES.
        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
        • Danek BA
        • Karatasakis A
        • Karmpaliotis D
        • Alaswad K
        • Yeh RW
        • Jaffer FA
        • Patel MP
        • Mahmud E
        • Lombardi WL
        • Wyman MR
        • Grantham JA
        • Doing A
        • Kandzari DE
        • Lembo NJ
        • Garcia S
        • Toma C
        • Moses JW
        • Kirtane AJ
        • Parikh MA
        • Ali ZA
        • Karacsonyi J
        • Rangan BV
        • Thompson CA
        • Banerjee S
        • Brilakis ES
        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; 5e004272
        • Azzalini L
        • Poletti E
        • Ayoub M
        • Ojeda S
        • Zivelonghi C
        • La Manna A
        • Bellini B
        • Lostalo A
        • Luque A
        • Venuti G
        • Montorfano M
        • Agostoni P
        • Pan M
        • Carlino M
        • Mashayekhi K
        Coronary artery perforation during chronic total occlusion percutaneous coronary intervention: epidemiology, mechanisms, management, and outcomes.
        EuroIntervention. 2019; 15: e804-e811
        • Hirai T
        • Nicholson WJ
        • Sapontis J
        • Salisbury AC
        • Marso SP
        • Lombardi W
        • Karmpaliotis D
        • Moses J
        • Pershad A
        • Wyman RM
        • Spaedy A
        • Cook S
        • Doshi P
        • Federici R
        • Nugent K
        • Gosch KL
        • Spertus JA
        • Grantham JA
        OPEN-CTO Study Group. A detailed analysis of perforations during chronic total occlusion angioplasty.
        JACC Cardiovasc Interv. 2019; 12: 1902-1912
        • Kinnaird T
        • Anderson R
        • Ossei-Gerning N
        • Cockburn J
        • Sirker A
        • Ludman P
        • deBelder M
        • Walsh S
        • Smith E
        • Hanratty C
        • Spratt J
        • Strange J
        • Hildick-Smith D
        • Mamas MA.
        British Cardiovascular Intervention Society and the National Institute for Cardiovascular Outcomes Research. Legacy effect of coronary perforation complicating percutaneous coronary intervention for chronic total occlusive disease: an analysis of 26 807 cases from the British Cardiovascular Intervention Society Database.
        Circ Cardiovasc Interv. 2017; 10e004642
        • Wu K
        • Huang Z
        • Zhong Z
        • Liao H
        • Zhou Y
        • Luo B
        • Zhang B.
        Predictors, treatment, and long-term outcomes of coronary perforation during retrograde percutaneous coronary intervention via epicardial collaterals for recanalization of chronic coronary total occlusion.
        Catheter Cardiovasc Interv. 2019; 93: 800-809
        • Tarar MN
        • Christakopoulos GE
        • Brilakis ES.
        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
        • Brilakis ES.
        Manual of Percutaneous Coronary Interventions: a Step-by-Step Approach.
        Academic Press, London2021
        • Sandoval Y
        • Lobo AS
        • Brilakis ES.
        Covered stent implantation through a single 8-french guide catheter for the management of a distal coronary perforation.
        Catheter Cardiovasc Interv. 2017; 90: 584-588
        • Kostantinis S
        • Brilakis ES.
        When and how to close vessels in the cardiac catheterization laboratory.
        Catheter Cardiovasc Interv. 2021; 98: 1332-1334
        • Shemisa K
        • Karatasakis A
        • Brilakis ES.
        Management of guidewire-induced distal coronary perforation using autologous fat particles versus coil embolization.
        Catheter Cardiovasc Interv. 2017; 89: 253-258
        • Guddeti RR
        • Kostantinis ST
        • Karacsonyi J
        • Brilakis ES.
        Distal coronary perforation sealing with combined coil and fat embolization.
        Cardiovasc Revasc Med. 2021; (])https://doi.org/10.1016/j.carrev.2021.12.001
        • Kotsia AP
        • Brilakis ES
        • Karmpaliotis D.
        Thrombin injection for sealing epicardial collateral perforation during chronic total occlusion percutaneous coronary interventions.
        J Invasive Cardiol. 2014; 26: E124-E126