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| ==Classification==
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| The Ellis Classification<ref name="pmid7994814">{{cite journal |author=Ellis SG, Ajluni S, Arnold AZ, ''et al.'' |title=Increased coronary perforation in the new device era. Incidence, classification, management, and outcome |journal=Circulation |volume=90 |issue=6 |pages=2725–30 |year=1994 |month=December |pmid=7994814 |doi= |url=}}</ref> categorizes coronary artery perforations based on their [[angiographic]] appearance in the following manner:
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| * '''Type I''' - Extraluminal crater without [[extravasation]]
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| * '''Type II''' - [[Epicardial]] fat or myocardial blush without contrast jet extravasation
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| * '''Type III''' - Extravasation through frank (> 1 mm) perforation
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| * '''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
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| | Surgical closure is necessary for perforations that demonstrate continued bleeding despite minimal invasive therapy, refractory [[ischemia]], or recurrent [[hemorrhage]]. |
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| ==Advantages of Each Choice==
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| 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.
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| [[PTFE]] coated stent placement can rapidly and effectively close vessel wall defects, obviating open surgical procedures.
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| Surgical repair offers the advantage of visualizing difficult-to-identify perforations. [[Cardiopulmonary bypass]] may be needed to [[hemodynamically]] stabilize patients with perforations.
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| Coil [[embolization]] is suitable for small side branch perforations, but it will lead to tissue infarction and may not be available in all [[Cath lab|catheterization laboratories]].
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| ==Making a Selection==
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| Initial management of perforations should always begin with prolonged balloon inflation.
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| 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.
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| Coil [[embolization]] is suited for small vessels, distal locations, arteries that supply limited viable [[myocardium]], or situations where surgery is [[contraindicated]].
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| Surgical closure is necessary for perforations that demonstrate continued bleeding despite minimal invasive therapy, refractory [[ischemia]], or recurrent [[hemorrhage]].
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| [[Pericardiocentesis]] is indicated to prevent overt cardiac [[tamponade]] for all patients who accumulate [[pericardial]] fluid as evidenced by increasing right atrial pressure.
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| ==Is Treatment Working?== | | ==Is Treatment Working?== |
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| Serial echocardiography should be performed q 6-12h. | | Serial echocardiography should be performed q 6-12h. |
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| ==References==
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| {{reflist}}
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| {{SIB}}
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| [[Category:Cardiology]]
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| {{WikiDoc Help Menu}}
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Surgical closure is necessary for perforations that demonstrate continued bleeding despite minimal invasive therapy, refractory ischemia, or recurrent hemorrhage.
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.