Coronary artery perforation during PCI

1. CORONARYARTERY
PERFORATIONDURINGPCI
Dr. Md. Ahasanul Kabir
Resident, Phase B
UCC, BSMMU

2. Coronary Perforation
• Coronary artery perforation is defined as evidence of
extravasation of contrast medium or blood from the coronary
artery, during or following percutaneous intervention.

3. Anatomical categories
 Anatomically,perforation iscategorizedas–
 Proximalor midvessel
• Usuallymore profound with greater likelihood of significantsequelae
 Distalvessel
• Therethe aetiology isoften the guidewire(WIRE EXIT)andthe clinicalcourseis
frequentlybenign

4. Classification
 Themost frequently adopted classificationis proposed byEllisin
1994

6. Other classifications
•Fukutomi1
 TypeI: Epicardialstaining without acontrast extravasation
 TypeII: Epicardialstaining with avisible jet ofcontrast extravasation
•Kini2
 TypeI: Myocardial staining withoutcontrast extravasation
 TypeII: Contrastextravasationintopericardium, coronary sinus,
or cardiacchambers
1.Fukutomi T,SuzukiT,PopmaJJ,et al. Early and late clinical outcomes following coronary perforation in patients undergoing percutaneouscoronary intervention. CircJ2002;66:349-56.
2.Kini AS,Rafael OC,SarkarK,et al. Changingoutcomes and treatment strategies for wire inducedcoronary perforations in the era of bivalirudin use.CatheterCardiovascInterv2009;74:700-7.

7. Incidence and outcomes
 Theincidence of CoronaryArtery Perforation(CAP) hasnot
changedsignificantly over twodecades.
 It isreported between 0.2%and0.9%.

8. Diagnosis
 Not all perforations are immediately visible oncoronary
angiography.
 Remarkableproportion of patients maydeveloptamponade
more than 2 to 6 hours afterprocedure.
 Theclinical manifestation maybe non-specific, andthe
patient maysimply develop progressivehypotension.
 Ahigh index of suspicion should be maintained in orderto
securethe correct diagnosis in atimelyfashion.

9. Outcomes
 In various studies, outcomes depend largely uponthe severity of
perforation.
 Theoutcome isworseif the temponade developsabruptly within the
catheter laboratory, rather than in the delayed fashion in the recovery
room orICU.
 Outcomes alsodepend upon associatedco-morbidities.
o Chronicrenaldysfunction
o Pre-procedural impairment of LVfunction
o Older patient
 Cavitaryspilling type IIIperforation

10. Lesion characteristics
 Calcification
 Tortuosity
 Eccentricplaque
 AHA/ACCclassBor Clesions
 Smallcalibre vessel
 CTOlesions

11. Treatment

12.  Most important step isto recognizeandidentify
presenceof aperforation.
• High indexofsuspicion
 Subtlesigns:Unusualmigration of wire tip,dye
staining, unexplained hypotension

13. Strategy
 Strategydependsupon –
 Site of theperforation
 Severityof theinsult
 Hemodynamic stability ofpatient
 Persistentbleeding

14.  Supportive measures
 Intravenous fluids
 Oxygen
 Analgesia
 Inotropic support
 Atropine
 Intra aortic ballooncounterpulsation

15. Type I perforations
 Usually respond to conservative measures.
 In anycase,indispensable measuresare:
o Fastidiouspost-procedural care
o Cautiousmonitoring of hemodynamicparameters
o At least one, andif required, serialechocardiographic assessment.

16. Type II or III perforations
 Initial managementissimilar.
 First objective isto stopbleeding.
 Immediatestepisto inflate aballoon at the site of bleeding if it isin
the mid or proximal vessel,andmore distally for a remotely situated
wire perforation to buy the time for further strategymaking.
 Thisprevents the development of temponade,and favourably
altersthe outlook of the situation.

17.  In significant proportion of cases,prolonged balloon dilatation isall
that isrequired.
 Ballooninflation for upto 30min isrequired.
 If the patient cannot tolerate ischemia,then perfusion balloon, if
available maybehelpful.
 Fukotomi reported excellent results usingperfusionballoon for Ellistype III
rupture
Fukutomi T,SuzukiT,PopmaJJ,et al. Early and late clinical outcomes following coronary perforation in patients undergoing percutaneous
coronary intervention. CircJ2002;66:349–356.

18. Covered stent
Frank rupture of proximal or mid coronary artery often constitute a tear
in the vessel, upto 5 mm in length.
Deploying a covered stent isolates the point of haemorrhage from the
circulation.
The most widely used device is PTFE covered stent.
Sandwich design
Inflexible, difficult to deliver in certain areas

19. Distal perforation
If conventional measures fail, vessel may be occluded by –
Platinum microcoils (Trufill – Terumo)
Injection of Thrombin
Autologous clotted blood
Subcutaneous adipose tissue
Tris-Acryl gelatin microspheres
Polyvinyl alcohol foam

20. Emergency surgery
Cases not responding to conventional measures are sent for emergency
surgery
 These perforations are frank ruptures, and not modest distal
perforations.
 Ellis reports 63% of type III perforations had to go for surgery, while
very few of type I or type II underwent surgery.

21. Surgical outcomes
The results are disappointing.
The mortality of emergency surgery in reports of both Fejka and Witzke
was 50%.

23. Thank you