PCI complications: vessel perforation: Difference between revisions
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==Diagnosis== | ==Diagnosis== | ||
Perforation is an angiographic diagnosis. It appears as a small extraluminal extravasation of blush in the distribution of the target vessel. Care should be taken to routinely visualize the distal extent of the vessel following PCI to exclude the presence of a wire perforation. Emergency echocardiography should be performed to rule out the presence of a [[pericardial effusion]] or [[pericardial tamponade]]. | Perforation is an angiographic diagnosis. It appears as a small extraluminal extravasation of blush in the distribution of the target vessel. Care should be taken to routinely visualize the distal extent of the vessel following PCI to exclude the presence of a wire perforation. Emergency echocardiography should be performed to rule out the presence of a [[pericardial effusion]] or [[pericardial tamponade]]. | ||
==Classification== | ==Classification== | ||
Revision as of 13:01, 25 October 2011
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]
Overview
Coronary perforations are uncommon (< 1%) complications of percutaneous coronary intervention (PCI) and are associated with significant morbidity and mortality rates. [1] [2] [3] [4] [5] Coronary perforations are infrequent in patients undergoing balloon angioplasty (0.1%) compared with patients undergoing atheroablative therapy (1.3%; P< 0.001) [6] [7] Perforation due to coronary guidewires may present late after the procedure.
Risk Factors
PCI Equipment
- The use of stiff guidewires, hydrophilic guidewires and guidewires in which the core extends to the tip of the guidewire are associated with perforation.
PCI Technique
- Balloon to artery ratio > 1.1
- Over expansion of a stent at high pressures
- Use of debulking procedure such as rotational atherectomy
Lesion Risk Factors
Complex coronary anatomy including:
Diagnosis
Perforation is an angiographic diagnosis. It appears as a small extraluminal extravasation of blush in the distribution of the target vessel. Care should be taken to routinely visualize the distal extent of the vessel following PCI to exclude the presence of a wire perforation. Emergency echocardiography should be performed to rule out the presence of a pericardial effusion or pericardial tamponade.
Classification
The following classification scheme has been developed based on angiographic appearance of the perforation:
- Type I perforations including an extraluminal crater without extravasation
- Type II perforations containing pericardial or myocardial blushing
- Type III perforations having a ≥ 1 mm diameter with contrast streaming; and cavity spilling [8].
Coronary Artery Perforation
Shown below is perforation of the right coronary artery during PCI: <youtube v=sFSKnzL1kp0/>
- Class I perforations were associated with no deaths and cardiac tamponade in 8% of patients.
- Class II perforations were associated with no deaths and cardiac tamponade in 13% of cases
- Class III perforations were associated with death in 19% and cardiac tamponade in 63% of patients [9].
Management of Vessel Perforation
Initial management strategies include:
- Prolonged balloon inflation: For this reason it is often wise for a cardiac catheterization laboratory to have perfusion balloons in a range of sizes available.
- Reversal of anticoagulation: This would included administration of protamine to reverse heparin and administration of platelets if abciximab has been administered.
- In refractory cases, polytetrafluoroethylene covered stents (stent grafts) can be used to seal the perforation [10] [11] .
- The administration of platelets can be considered to reverse the effects of antiplatelet agents.
- The administration of protamine can be considered to reverse the effects of unfractionated heparin. Protamine will also partially reverse the antithrombotic effect of enoxaparin if this antithrombin was used.
- Other techniques include coil embolization, the injection of clotted blood, the use of gel foam and the injection of thrombin at the site of the perforation.
Approximately one third of cases of PCI-associated coronary artery perforation require emergent cardiac surgery.
References
- ↑ Fasseas P, Orford JL, Panetta CJ, Bell MR, Denktas AE, Lennon RJ, Holmes DR, Berger PB. Incidence, correlates, management, and clinical outcome of coronary perforation: analysis of 16,298 procedures. Am Heart J. 2004 Jan; 147 (1):140-5. PMID 14691432
- ↑ Dippel EJ, Kereiakes DJ, Tramuta DA, Broderick TM, Shimshak TM, Roth EM, Hattemer CR, Runyon JP, Whang DD, Schneider JF, Abbottsmith CW. Coronary perforation during percutaneous coronary intervention in the era of abciximab platelet glycoprotein IIb/IIIa blockade: an algorithm for percutaneous management. Catheter Cardiovasc Interv. 2001 Mar; 52 (3):279-86. PMID 11246236
- ↑ Javaid A, Buch AN, Satler LF, Kent KM, Suddath WO, Lindsay J Jr, Pichard AD, Waksman R. Management and outcomes of coronary artery perforation during percutaneous coronary intervention. Am J Cardiol. 2006 Oct 1; 98 (7):911-4. Epub 2006 Aug 7. PMID 16996872
- ↑ Klein LW. Coronary artery perforation during interventional procedures. Catheter Cardiovasc Interv. 2006 Nov; 68 (5):713-7.PMID 17039517
- ↑ Stankovic G, Orlic D, Corvaja N, Airoldi F, Chieffo A, Spanos V, Montorfano M, Carlino M, Finci L, Sangiorgi G, Colombo A. Incidence, predictors, in-hospital, and late outcomes of coronary artery perforations. Am J Cardiol. 2004 Jan 15; 93 (2): 213-6. PMID 14715351
- ↑ Dippel EJ, Kereiakes DJ, Tramuta DA, Broderick TM, Shimshak TM, Roth EM, Hattemer CR, Runyon JP, Whang DD, Schneider JF, Abbottsmith CW. Coronary perforation during percutaneous coronary intervention in the era of abciximab platelet glycoprotein IIb/IIIa blockade: an algorithm for percutaneous management. Catheter Cardiovasc Interv. 2001 Mar; 52 (3):279-86. PMID 11246236
- ↑ Ellis SG, Ajluni S, Arnold AZ, Popma JJ, Bittl JA, Eigler NL, Cowley MJ, Raymond RE, Safian RD, Whitlow PL. Increased coronary perforation in the new device era. Incidence, classification, management, and outcome. Circulation. 1994 Dec; 90 (6): 2725-30. PMID 7994814
- ↑ Ellis SG, Ajluni S, Arnold AZ, Popma JJ, Bittl JA, Eigler NL, Cowley MJ, Raymond RE, Safian RD, Whitlow PL. Increased coronary perforation in the new device era. Incidence, classification, management, and outcome. Circulation. 1994 Dec; 90 (6): 2725-30. PMID 7994814
- ↑ Ellis SG, Ajluni S, Arnold AZ, Popma JJ, Bittl JA, Eigler NL, Cowley MJ, Raymond RE, Safian RD, Whitlow PL. Increased coronary perforation in the new device era. Incidence, classification, management, and outcome. Circulation. 1994 Dec; 90 (6): 2725-30. PMID 7994814
- ↑ Ly H, Awaida JP, Lespérance J, Bilodeau L. Angiographic and clinical outcomes of polytetrafluoroethylene-covered stent use in significant coronary perforations. Am J Cardiol. 2005 Jan 15; 95 (2): 244-6. PMID 15642559
- ↑ Gercken U, Lansky AJ, Buellesfeld L, Desai K, Badereldin M, Mueller R, Selbach G, Leon MB, Grube E. Results of the Jostent coronary stent graft implantation in various clinical settings: procedural and follow-up results. Catheter Cardiovasc Interv. 2002 Jul; 56 (3): 353-60. PMID 12112888