Coronary interventions

Coronary artery perforation during chronic total occlusion percutaneous coronary intervention: epidemiology, mechanisms, management, and outcomes

EuroIntervention 2019;15:e804-e811. DOI: 10.4244/EIJ-D-19-00282

Lorenzo Azzalini
Lorenzo Azzalini1, MD, PhD, MSc; Enrico Poletti1, MD; Mohamed Ayoub2, MD; Soledad Ojeda3, MD, PhD; Carlo Zivelonghi4, MD; Alessio La Manna5, MD; Barbara Bellini1, MD; Adrián Lostalo3, MD; Aurora Luque3, MD; Giuseppe Venuti5, MD; Matteo Montorfano1, MD; Pierfrancesco Agostoni4, MD, PhD; Manuel Pan3, MD, PhD; Mauro Carlino1, MD; Kambis Mashayekhi2, MD
1. Interventional Cardiology Division, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy; 2. Department of Cardiology and Angiology II, University Heart Center Freiburg, Bad Krozingen, Germany; 3. Interventional Cardiology Division, Reina Sofia Hospital, University of Córdoba, Maimonides Institute for Research in Biomedicine of Córdoba (IMIBIC), Córdoba, Spain; 4. Hartcentrum, Ziekenhuis Netwerk Antwerpen Middelheim, Antwerp, Belgium; 5. Cardiology Division, Policlinico University Hospital, University of Catania, Catania, Italy

Aims: The aim of this study was to describe the epidemiology, mechanisms, management, and outcomes of coronary artery perforation during chronic total occlusion (CTO) percutaneous coronary intervention (PCI).

Methods and results: We included 1,811 consecutive patients undergoing CTO PCI at five centres between 2011 and 2018. Coronary perforation was observed in n=99 (5.5%). Patients with perforation were older, had a higher J-CTO score, more often required antegrade dissection/re-entry and the retrograde approach, and had lower success rates. The frequency of Ellis type I, II, III and III “cavity spilling” perforations was 11%, 46%, 28%, and 14%, respectively. In 48% of cases, perforation involved the CTO vessel, while the retrograde approach was responsible for 46% of cases. In 53% of cases perforations required intervention. The most frequently applied management strategies included clinical observation (47%), covered stent implantation (25%), balloon occlusion (9%), and coil/fat embolisation (9%). Tamponade was observed in 20/99 (20%) perforation cases. Ellis type III perforations were most frequently observed at the CTO site. These were accountable for 16/20 tamponades and 3/5 deaths. In-hospital mortality was 5.1% vs 0.3% in patients with versus those without perforation (p<0.001). Older age, occlusion length >20 mm, rotational atherectomy, antegrade dissection/re-entry, and the retrograde approach were independently associated with coronary perforation. Patients with perforation suffered an increased incidence of target vessel failure on short-term follow-up.

Conclusions: Coronary perforation is observed in a non-negligible proportion of CTO PCIs, often requires intervention, and is associated with tamponade and mortality in a minority of patients. CTO vessel-related perforations are associated with the highest burden of morbidity and mortality.

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chronic coronary total occlusionCoronary rupturepericardial effusion
Coronary interventionsCTO
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