Coronary Artery Perforation: Difference between revisions

Revision as of 13:12, 25 October 2011

Classification

The Ellis Classification^[1] categorizes coronary artery perforations based on their angiographic appearance in the following manner:

Type I - Extraluminal crater without extravasation
Type II - Epicardial fat or myocardial blush without contrast jet extravasation
Type III - Extravasation through frank (> 1 mm) perforation
Type III "cavity spilling" (CS) - Refers to Type III perforations with contrast spilling directly into either the left ventricle, coronary sinus, or another anatomic circulatory chamber

Advantages of Each Choice

Prolonged balloon inflations can be performed rapidly. However, patients may not tolerate balloon inflations because of the development of ischemia, arrhythmias, or hemodynamic instability. Therefore, perfusion balloon use may be optimal if it is available.

PTFE coated stent placement can rapidly and effectively close vessel wall defects, obviating open surgical procedures.

Surgical repair offers the advantage of visualizing difficult-to-identify perforations. Cardiopulmonary bypass may be needed to hemodynamically stabilize patients with perforations.

Coil embolization is suitable for small side branch perforations, but it will lead to tissue infarction and may not be available in all catheterization laboratories.

Making a Selection

Initial management of perforations should always begin with prolonged balloon inflation.

Once prolonged balloon inflation is attempted, other options may be explored. PTFE coated stents have now become more readily available and are deployed more frequently. They can be used for most coronary perforations, but small, excessively angulated or tortuous vessels may not be amenable to them.

Coil embolization is suited for small vessels, distal locations, arteries that supply limited viable myocardium, or situations where surgery is contraindicated.

Surgical closure is necessary for perforations that demonstrate continued bleeding despite minimal invasive therapy, refractory ischemia, or recurrent hemorrhage.

Pericardiocentesis is indicated to prevent overt cardiac tamponade for all patients who accumulate pericardial fluid as evidenced by increasing right atrial pressure.

Is Treatment Working?

There are several signs that indicate whether treatment is failing. Incomplete closure is signified by persistent dye extravasation, while pericardial fluid collection and impending cardiac tamponade is signified by increasing right atrial pressure. Peristent fluid accumulation or pericardial drain output (>24 h) should prompt surgical repair.

Serial echocardiography should be performed q 6-12h.

References

↑ Ellis SG, Ajluni S, Arnold AZ; et al. (1994). "Increased coronary perforation in the new device era. Incidence, classification, management, and outcome". Circulation. 90 (6): 2725–30. PMID 7994814. Unknown parameter |month= ignored (help)

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[pmid7994814-1] Ellis SG, Ajluni S, Arnold AZ; et al. (1994). "Increased coronary perforation in the new device era. Incidence, classification, management, and outcome". Circulation. 90 (6): 2725–30. PMID 7994814. Unknown parameter |month= ignored (help)

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-==Goals of Treatment==
-There are several goals involved in treating perforations.  Prevention of complications such as [[tamponade]], [[MI|myocardial infarction (MI)]] and death is critical.  It is important to maintain [[hemodynamic]] stability.  Should tamponade occur, it is important to detect and treat it immediately.  Additionally, a goal of treatment is to decrease the need for emergent [[bypass surgery]].
-Prolonged balloon inflation may be another treatment option.  Immediate occlusion of the perforated vessel at the perforation site for 10 minutes at 2-4 [[atms]] is recommended. If there is continued evidence of perforation, use perfusion balloons (if available) to allow for prolonged inflation without inducing myocardial [[ischemia]].
-Other measures can be considered after prolong balloon inflation is initiated.  Coil [[embolization]] and [[IABP|intra aortic balloon pump (IABP)]] counterpulsation are two options.
-Additionally, [[polytetrafluoroethylene|polytetrafluoroethylene (PTFE)]] covered stents (Jomed stent)<ref name="pmid15084537">{{cite journal |author=Fineschi M, Gori T, Sinicropi G, Bravi A |title=Polytetrafluoroethylene (PTFE) covered stents for the treatment of coronary artery aneurysms |journal=Heart |volume=90 |issue=5 |pages=490 |year=2004 |month=May |pmid=15084537 |pmc=1768192 |doi= |url=}}</ref> can seal the perforation site.  However, the stent is bulky and can be difficult to deploy.  To decrease the timing between deflation of balloon and deployment of the stent, bilateral [[groin]] access with the two guide catheters approach should be considered.
-Adjunctive hemodynamic monitoring and support is another option for treatment.  Hemodynamic assessment with right heart pressure monitoring should be considered, but it is important to pay particular attention to a sudden rise in right [[atrial]] filling pressures.  Also, it is important to monitor heart borders on [[fluoroscopy]] to detect signs of [[tamponade]], as signified by a lack of movement of the heart borders.
-Urgent [[echocardiography]] is an option to evaluate for [[pericardial effusion]] and [[tamponade]] [[physiology]].  Immediate notification of the [[Cardiac surgery|cardiothoracic surgical]] team is important.
 ==Advantages of Each Choice==