Background: Coronary perforation during percutaneous coronary intervention is a rare but dreaded complication. The risk factors, optimal management, and outcome remain obscure. Objectives: To determine the predisposing factors, optimal management, and preventive strategies. We retrospectively looked at coronary perforations at our catheterization laboratory over the last 10 years. We reviewed patient charts and reports. Two independent operators, in a blinded approach, reviewed all procedural cineangiograms. Data were analyzed by simple statistical methodology. Results: Nine patients were treated conservatively and six patients were treated with prolonged balloon inflation. Six patients were treated with polytetrafluoroethylene (PTFE)-covered stents. One patient required emergency coronary artery bypass graft. No deaths were reported. Subjects with perforations also had a significantly higher total white blood cell count (means 12,134 versus 6,155, 95 % confidence interval [CI], p<0.0001, n=22), total absolute neutrophil count (means 74.2 % versus 57.1 %, 95 % CI, p<0.0001, n=22), and neutrophil:lymphocyte ratio (means 3.65 versus 1.50, 95% CI, p<0.0001, n=22). Conclusions: Coronary perforations are rare but potentially fatal events. Hypertension, small vessel diameter, high balloon:artery ratio, use of hydrophilic wires, and presence of myocardial bridging appear to be possible risk factors. Most perforations can be treated conservatively or with prolonged balloon inflation using perfusion balloons. Use of PTFE-covered stents could be a life-saving measure in cases of large perforations. Subjects with perforations also had greater systemic inflammation as indicated by elevated white cell counts.
Coronary perforation (CP) during percutaneous coronary intervention (PCI) is a rare complication, but is associated with significant morbidity and mortality.1 CPs have been reported to occur in association with coronary wires, balloons, atheroablative devices, stenting, and laser angioplasty.2–6 Vessel punctures can often be treated conservatively with prolonged balloon inflation,7 coil embolization,8,9 or polytetrafluoroethylene (PTFE)-covered stents,10 while vessel ruptures with cardiac tamponade and hemodynamic compromise often necessitate emergency surgery. Prior studies have determined risk factors that place patients at higher risk of CP, including increasing age, female gender, heavy calcification, target lesions in the left circumflex and right coronary arteries, long target lesions (>10 mm), and eccentric lesions.6,11,12 The objectives of the study were to determine the predisposing factors, optimal management, and possible preventive strategies in all subjects developing perforations during PCI in a single center between 2000 and 2009 and also to see if arterial inflammation, by causing possible increased friability of vessel walls, conferred a higher risk of perforations.
All subjects developing perforations between 2000 and 2009 were retrospectively looked at using chart reviews and retrieval of records from a computerized catheterization laboratory database. The study design was approved by the institutional review board (IRB) at Maimonides Medical Center. We reviewed patient charts and reports. Two independent operators, in a blinded approach, reviewed all procedural cineangiograms. Data were analyzed by simple statistical methodology. Twenty-two subjects out of 30,798 subjects undergoing PCI (0.07 %) met criteria for inclusion in the study. We also tabulated their white blood cell (WBC) counts and absolute neutrophil (N) and lymphocyte (L) counts (as percentages), as well as N/L ratios (Group I). We compared the data with a random group of age- and gender-matched controls (n=22), with similar lesion characteristics but without perforations (Group II), from our database. The authors of this article have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology.13
Demographic and angiographic features are revealed in Tables 1 and 2.
Nine patients were treated conservatively and six patients were treated with prolonged balloon inflation. Six patients were treated with PTFE-covered stents. One patient required emergency coronary artery bypass graft. No deaths were reported.
Role of Arterial Inflammation
Group I had a significantly higher total WBC count (means 12,134 versus 6,155, 95 % confidence interval [CI], p<0.0001, n=22), total absolute neutrophil count (means 74.2 % versus 57.1 %, 95 % CI, p<0.0001, n=22), and N/L ratio (means 3.65 versus 1.50, 95 % CI, p<0.0001, n=22).
Types 1 and 2 perforations had classically been treated conservatively, while Type 3 required emergency pericardiocentesis. In our series, most of the patients fared well with conservative treatment. Hypertension, small vessel diameter, high balloon:artery ratio, use of hydrophilic wires, and presence of myocardial bridging were strongly associated with perforations and may be postulated to be hitherto unknown possible risk factors. A recent article has put forward a dual catheter technique for treatment of severe CP (Ellis Type 2 or 3), which may reduce requirements for emergency surgery even more for CP.14 Our data also suggest a pre-procedural elevated WBC count, with an elevated percentage of neutrophils and an elevated N/L ratio, is a predictor of CP in patients undergoing PCI, thereby indicating a possible role of arterial inflammation in causing friability of arterial walls15 leading to greater tendency for CPs in subjects. This hypothesis will soon be tested with a larger sample size in pilot study using American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR) data.
- Shirakabe A, Takano H, Nakamura S, et al., Coronary perforation during percutaneous coronary intervention, Int Heart J, 2007;48(1):1–9.
- Ellis SG, Ajluni S, Arnold AZ, et al., Increased coronary perforation in the new device era: Incidence, classification, management and outcome, Circulation, 1994;90:2725–30.
- Ajluni SC, Glazier S, Blankenship L, et al., Perforation after percutaneous coronary interventions: Clinical, angiographic, and therapeutic observations, Cathet Cardiovasc Diagn, 1994;32:206–12.
- Ramsdale DR, Mushahwar SS, Morris JL, Repair of coronary artery perforation after rotastenting by implantation of the JoStent covered stent, Cathet Cardiovasc Diagn, 1998;45:310–3.
- Casella G, Werner F, Klauss V, et al., Successful treatment of coronary artery perforation during angioplasty using a new membrane-coated stent, J Invasive Cardiol, 1999;11:622–6.
- Gruberg L, Pinnow E, Flood R, et al., Incidence, management, and outcome of coronary artery perforation during percutaneous coronary intervention, Am J Cardiol, 2000;88:680–2, A8.
- Hadjimiltiades S, Paraskevaides S, Kazinakis G, Louridas G, Coronary vessel perforation during balloon angioplasty, Cathet Cardiovasc Diagn, 1998;45:417–20.
- Gaxiola E, Browne KF, Coronary artery perforation repair using microcoil embolization, Cathet Cardiovasc Diagn, 1998;43:474–6.
- Assali AR, Moustapha A, Sdringola S, et al., Successful treatment of coronary artery perforation in an abciximab-treated patient by microcoil embolization, Catheter Cardiovasc Interv, 2000;51:487–9.
- Nageh T, Thomas MR, Coronary-artery rupture treated with a polytetrafluoroethylene-coated stent, N Engl J Med, 2000;342:1922–4.
- Wong CM, Kwong GY, Chung DT, Distal coronary artery perforation resulting from the use of hydrophilic coated guidewire in tortuous vessels, Cathet Cardiovasc Diagn, 1998;44:93–6.
- Gunning MG, Williams IL, Jewitt DE, et al., Coronary artery perforation during percutaneous intervention: Incidence and outcome, Heart, 2002;88:495–8.
- Shewan LG, Coats AJ, Ethics in the authorship and publishing of scientific articles, Int J Cardiol, 2010;144:1–2.
- Ben-Gal Y, Weisz G, Collins MB, et al., Dual catheter technique for the treatment of severe coronary artery perforations, Catheter Cardiovasc Interv, 2010;75(5):708–12.
- Tamhane UU, Aneja S, Montgomery D, et al., Association between admission neutrophil to lymphocyte ratio and outcomes in patients with acute coronary syndrome, Am J Cardiol, 2008;102(6):653–7.