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