PCI complications: vessel perforation

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Sudarshan Srivats, M.D., M.P.H.[2], Cafer Zorkun, M.D., Ph.D. [3]

Percutaneous coronary intervention Microchapters

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Risk Stratification and Benefits of PCI

Preparation of the Patient for PCI

Equipment Used During PCI

Pharmacotherapy to Support PCI

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Recommendations for Perioperative Management–Timing of Elective Noncardiac Surgery in Patients Treated With PCI and DAPT

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Post-PCI follow up

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PCI Complications

Factors Associated with Complications
Vessel Perforation
Dissection
Distal Embolization
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Abrupt Closure
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Restenosis
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Thrombocytopenia
Late Acquired Stent Malapposition
Loss of Side Branch
Multiple Complications

PCI in Specific Patients

Cardiogenic Shock
Left Main Coronary Artery Disease
Refractory Ventricular Arrhythmia
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Adjuncts for High Risk PCI

PCI in Specific Lesion Types

Classification of the Lesion
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Overview

Coronary artery perforation (CAP) is an uncommon but potentially catastrophic complication of percutaneous coronary intervention (PCI). It complicates roughly 0.3–0.7% of all-comer PCIs and 3.7–5.5% of chronic total occlusion (CTO) procedures, and contemporary rates have not fallen despite device evolution. Severity ranges from an angiographically trivial extraluminal crater to frank contrast jetting with rapid cardiac tamponade, cardiogenic shock, emergency surgery, and death. The angiographic Ellis classification remains the reference grading system and drives prognosis and urgency of response, while mechanism (device- vs guidewire-related) and location (proximal vessel, distal vessel, septal or epicardial collateral) determine treatment. CTO PCI, particularly the retrograde approach through epicardial collaterals, is now the dominant driver of serious perforation, and validated CTO perforation risk scores allow pre-procedural risk estimation. Management is a time-critical, stepwise, location-based algorithm: immediate low-pressure balloon tamponade for every perforation, urgent echocardiography, pericardiocentesis only for tamponade, covered stents for large or proximal vessel perforations, and embolization (autologous fat, coils, or thrombin) for distal and collateral perforations. Anticoagulation reversal is deferred until intracoronary equipment is removed and reserved for persistent bleeding. Distal guidewire perforations are an important cause of delayed tamponade hours to days after the procedure, mandating extended observation with serial echocardiography.

Epidemiology

  • All-comer PCI: pooled incidence 0.43% (95% CI 0.35–0.52%) across 16 studies (197,061 PCIs).[1] Contemporary registries are concordant: 0.37% in the NCDR CathPCI Registry (13,779 of 3,759,268 PCIs, 2009–2015)[2] and 0.33% in the British Cardiovascular Intervention Society (BCIS) database.[3]
  • Secular trend: perforation rates have not declined over time and have risen in some series as procedural complexity has increased.[2][4]
  • CTO PCI: 4.9% in the PROGRESS-CTO registry (10,454 procedures), with dedicated CTO registries reporting 3.7–5.5%.[5]
  • Atheroablation: in the original Ellis cohort, perforation occurred in 1.3% with atheroablative devices vs 0.1% with balloon angioplasty alone (p<0.001).[6] Rotational atherectomy perforation rates in contemporary registries are approximately 0.6–0.9%.[2][3]
  • Outcome burden: CAP is associated with an approximately 5-fold increase in in-hospital mortality compared with uncomplicated PCI; most perforations (~75%) are recognized during the procedure.[7]

Classification

Ellis Classification

The angiographic Ellis classification remains the reference standard and is incorporated in the 2020 AHA/ACC Key Data Elements for Coronary Revascularization.[6][8]

Ellis type Angiographic definition Original Ellis cohort outcomes[6] Pooled tamponade[1] Pooled mortality[1]
Type I Extraluminal crater without extravasation (no linear staining suggestive of dissection) No deaths or MI; tamponade 8% 0.4% 0.3%
Type II Pericardial or myocardial blush without a ≥1 mm exit hole No deaths; MI 14%; tamponade 13% 3.3% 0.4%
Type III Frank streaming of contrast through a ≥1 mm exit hole Death 19%; MI 50%; tamponade 63%; urgent CABG 63% 45.7% 21.2%
Type III cavity-spilling (type 4) Contrast flow into an anatomic cavity (cardiac chamber, coronary sinus) rather than the pericardium or myocardium No deaths, MI, or tamponade (small sample) Low; pericardiocentesis usually not required[9] ~0% in reported series[9]

Cavity-spilling (type 4) perforation decompresses into a cardiac chamber, avoiding rapid pericardial accumulation; a pooled case review reported 0% in-hospital mortality without pericardiocentesis or surgery, with most lesions in the left anterior descending artery draining into the left ventricle.[9] It accounts for ~2–3% of all perforations but 11–14% of perforations in CTO registries.[9][5]

Ellis Type II Perforation

Ellis type II perforation: pericardial/myocardial blush without a ≥1 mm exit hole.

Ellis Type III Perforation

Ellis type III perforation: frank contrast streaming through a ≥1 mm exit hole; highest risk of tamponade and death.

Mechanistic and Anatomic Descriptors

Mechanism and location, rather than Ellis grade alone, dictate treatment:

  • Device-related vs guidewire-related: in the G3CAP registry of Ellis III perforations, device-related perforations (62.4%) were mostly proximal (73.2%), caused chiefly by balloon dilation, and managed with covered stents; guidewire-related perforations (37.6%; CTO wires in 61.3%) were more distal and managed with coil embolization. In-hospital mortality was higher with device-related perforation (7.2% vs 2.6%).[10]
  • Location: large/proximal vessel, distal vessel, septal collateral, and epicardial collateral; contemporary management algorithms branch on this distinction.[11][12]
  • Proposed Ellis type V (distal/guidewire): distal or side-branch wire-exit perforation, subdivided into definite (angiographic blush, Va) and probable "ghost" perforation (effusion without an identifiable angiographic source, Vb). This is a single-source proposal and is not endorsed by current guidelines.[13]

Risk Factors

Patient and Lesion Factors

Device and Technique Factors

  • Atherectomy (OR ~2.4).[2][3]
  • Balloon-to-artery ratio >1.1 (particularly >1.2:1) and high-pressure stent overexpansion or post-dilation.[11]
  • Cutting/scoring balloons and stiff, hydrophilic polymer-jacketed, or core-to-tip guidewires.[11][5]
  • CTO-specific: retrograde approach, antegrade dissection/re-entry, blunt or absent proximal cap stump, long occlusion, and prolonged guidewire manipulation (>60 min).[15]

CTO Perforation Risk Scores

In the PROGRESS-CTO development cohort, clinical perforation occurred in 3.8% (367/9,618) of CTO PCIs.[15]

Score Variables Discrimination Risk gradient
PROGRESS-CTO perforation score (0–5) Age ≥65 years (+1), moderate/severe calcification (+1), blunt/no stump (+1), antegrade dissection/re-entry (+1), retrograde approach (+2)[15] Development c-statistic 0.74[15]; external validation AUC 0.76[16] Development model: 0.7% (score 0) to 11.2% (score 5)[15]
External validation: 0.3% (score 0) to 14.6% (score 5)[16]
OPEN-CLEAN perforation score (0–7) Prior CABG (+1), occlusion length 20–<60 mm (+1) or ≥60 mm (+2), LVEF <50% (+1), age 50–<70 years (+1) or ≥70 years (+2), heavy calcification (+1)[17] Development c-statistic 0.75[17] External validation: 3.5% (score 0–1) to 19.8% (score 6–7)[18]

Diagnosis

  • CAP is an angiographic diagnosis: extraluminal contrast staining, blush, or frank streaming in the distribution of the target vessel.[6]
  • Routinely image the distal vessel and all wired side branches and collaterals after PCI, especially after CTO work or use of hydrophilic or stiff wires; unrecognized distal wire perforations are a major source of delayed tamponade.[11]
  • Abrupt hypotension, bradycardia, chest pain, or restlessness during or after PCI warrants immediate assessment for perforation and tamponade.[11]
  • Supportive findings: sudden rise in right atrial filling pressure on hemodynamic monitoring, loss of cardiac border motion on fluoroscopy, and an enlarging pericardial effusion on urgent transthoracic echocardiography.[11]
  • As little as ~100 mL of acutely accumulated pericardial blood can cause hemodynamic instability; early diastolic right ventricular collapse and late diastolic right atrial collapse precede hypotension.[13]
  • In prior-CABG patients, adhesions can produce a loculated hematoma ("dry tamponade") without circumferential effusion that is not drainable by standard pericardiocentesis.[12][19]
  • Pericardiocentesis is required in a minority of perforations (fewer than one-third in most series), with the need rising for large-vessel and LCx perforation;[7][20] a substantial proportion of tamponades are initially unrecognized.[21]

Management

No randomized trials or dedicated society guidelines exist for CAP management; recommendations derive from registries, case series, and expert consensus.[12][11]

Management Algorithm

 
 
 
 
Perforation recognized
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Low-pressure balloon tamponade (2–4 atm)
Stop GP IIb/IIIa infusion
Urgent echo; notify surgery if Ellis III
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Sealed:
observe ≥24 h with serial echo
 
 
 
Persistent leak
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Large/proximal vessel:
covered stent
 
 
 
Distal or collateral:
embolization
 

Pericardiocentesis for tamponade at any step; emergency CABG if percutaneous measures fail.

Step 1: Immediate Balloon Tamponade

  • For every perforation, inflate a balloon (usually the one already in the vessel) at or just proximal to the perforation site at the lowest effective pressure (2–4 atm) for 5–10 minutes, deflating periodically with contrast injection to assess sealing.[11]
  • Longer inflation may be needed, but ~20 minutes is the practical ischemic ceiling; use a perfusion balloon for prolonged tamponade, and keep perfusion balloons in a range of sizes available in the laboratory.[11]
  • Prolonged low-pressure balloon inflation is the first-line maneuver and controls many lower-grade perforations; in large-vessel perforation series it is used in ~71% of cases, with covered stents required in ~28%.[22]
  • For left main perforation, move early to a perfusion balloon or covered stent to avoid hemodynamic collapse.[11]

Step 2: Stabilization and Pericardial Management

  • Concurrently obtain urgent echocardiography and give IV fluids, atropine, and vasopressors as needed; consider mechanical circulatory support for hemodynamic compromise.[11]
  • Notify cardiac surgery immediately for any Ellis III perforation.[11]
  • Perform pericardiocentesis only for tamponade with hemodynamic or echocardiographic compromise; drain with a pigtail catheter and reinfuse aspirated blood (autotransfusion) to maintain stability while definitive sealing proceeds.[11]
  • Loculated hematomas in prior-CABG patients may require surgical or CT-guided drainage.[12][19]

Step 3: Definitive Sealing by Location

Large or Proximal Vessel: Covered Stent

Covered stents are the mainstay for large-vessel perforation and sealed 64% of device-related Ellis III perforations in G3CAP.[10] They may be unsuitable for small, excessively angulated, or tortuous vessels.[11]

Device Design Delivery Comparative data
PK Papyrus Single-layer polyurethane on cobalt-chromium; FDA approved 2018 under a Humanitarian Device Exemption (IRB approval and reporting required; off-label use restricted)[23][12] 5 Fr guide compatible[24] Lower stent thrombosis, tamponade/pericardiocentesis, and emergency CABG than PTFE stents; no mortality difference (observational, pooled)[25]
BeGraft Low-profile single-layer covered stent 5 Fr guide compatible[26]
GraftMaster Dual-layer polytetrafluoroethylene (PTFE) sandwich Requires 7–8 Fr guide; high-pressure post-dilation (>20 atm) Higher thrombosis and tamponade rates vs single-layer devices[25]

Delivery technique depends on hemodynamic stability and anatomy:[11]

  • Single-catheter: small perforations without hemodynamic compromise.
  • Ping-pong (dual-guide): second arterial access and guide used to deliver the covered stent while the first guide's balloon maintains hemostasis; preferred for instability or tortuous vessels.
  • Block-and-deliver (BAD): balloon and low-profile covered stent passed through a single 8 Fr guide.[27]
  • Guide-extension catheters can facilitate single-access delivery. Confirm expansion and apposition with intravascular ultrasound.[11]

Distal Vessel and Collateral: Embolization

  • Autologous subcutaneous fat: universally available, inexpensive, deliverable through any microcatheter; radiolucent unless soaked in contrast.[12]
  • Coil embolization: high technical success (94.5% in the perforation subgroup of the 143-patient multicenter COILSEAL registry); detachable coils (94% of coils used) allow controlled release.[28] Embolization causes infarction of the subtended territory and is best suited to distal locations, small vessels, or arteries supplying limited viable myocardium.[11]
  • Selective thrombin injection: 0.2–0.3 mL (~200–300 IU at 1,000 U/mL) injected slowly through a microcatheter under fluoroscopy with proximal balloon occlusion to prevent reflux; flush and withdraw the microcatheter afterward.[29]
  • The BAD technique also applies distally: a microcatheter is advanced alongside an occluding balloon through a single ≥6 Fr guide.[27]
  • Epicardial collateral perforation is life-threatening and requires embolization from both the antegrade and retrograde limbs; septal collateral perforation is usually benign but can rarely cause intraseptal hematoma.[12]

Antithrombotic Management

Agent Action Key points
Unfractionated heparin Do not reverse while wires, balloons, or stents remain in the coronary; reserve protamine for persistent bleeding, large perforations, or after hemodynamically significant effusions are drained[30] Protamine 1 mg per 100 U heparin administered (maximum single dose 50 mg, slow IV); reduce to 0.5 mg per 100 U if >30 min have elapsed since the heparin dose; ACT-guided titration[30][31][32]
Protamine before drainage promotes intrapericardial clot that impedes drainage[30]
If reversal is needed with equipment in place, maintain ACT >150 s and flush guides with heparinized saline; coronary thrombosis occurred in 7.6% and correlated with ACT <150 s[33]
Enoxaparin Protamine provides only partial reversal Same sequencing principles as heparin[30]
Glycoprotein IIb/IIIa inhibitors Stop infusion immediately Platelet transfusion may partially reverse effect[11]
P2Y12 inhibitors No clinically available reversal agents Platelet transfusion may help for clopidogrel or prasugrel if given ≥6 h after the last dose; little effect on ticagrelor; bentracimab remains investigational[34]

Emergency Surgery

Emergency CABG is reserved for failure of percutaneous sealing, ongoing bleeding, or refractory ischemia. Contemporary rates are far below the legacy "one-third" figure: ~3–6% of perforations in contemporary all-comer registries,[2][10] and only ~0.12% of all CTO PCIs overall (perforation being the most common trigger, 70.6%),[35] whereas historical Ellis III cohorts reported emergency CABG in 20–40%.[36]

Post-Procedure Monitoring and Delayed Tamponade

  • Delayed tamponade is reported in ~21–32% of perforations in contemporary series.[7] It is typically caused by distal guidewire perforation (often hydrophilic wires) and presents 30 minutes to 9 days after the procedure, most within ~5 hours.[37]
  • In a large PCI-tamponade series, 45% of tamponades presented in delayed fashion (mean 4.4 h), and no perforation site was angiographically identifiable in 79% of delayed cases.[21]
  • Monitor for at least 24 hours (ICU-level in high-risk cases, extendable up to a week) with serial echocardiography, and maintain a low threshold to re-image for hypotension.[38][19]
  • Exchange polymer-jacketed or stiff wires for soft workhorse wires as soon as the lesion is crossed.[11]
  • Optimal DAPT duration after covered stent implantation is undefined; 1-year stent thrombosis of ~6% in the CRACK registry suggests prolonged DAPT may be warranted.[39]

Prognosis

  • Short-term outcome is driven by Ellis grade (see Classification) and mechanism; device-related Ellis III perforations carry higher in-hospital mortality than guidewire-related perforations.[1][10]
  • Long-term "legacy effect": the BCIS CTO analysis and Michigan BMC2 registry found persistent excess mortality in perforation survivors (OR/HR ~1.6),[40][14] whereas a Japanese all-comer registry found no significant 2-year difference, likely reflecting infrequent tamponade and CTO in that cohort.[41]

Clinical Pearls and Pitfalls

  • In high-risk CTO PCI, calculate the PROGRESS-CTO or OPEN-CLEAN score and have covered stents, coils, microcatheters, a pericardiocentesis kit, and protamine in the room before starting.[15][17]
  • The balloon that caused the perforation is also the first treatment; inflate it before doing anything else.[11]
  • Cavity-spilling perforations are usually benign; recognizing them avoids unnecessary intervention.[9]
  • LCx perforations are disproportionately likely to require urgent pericardiocentesis (54% vs 21% in a multicenter type III series).[20]
  • A normal-appearing pericardium does not exclude loculated "dry tamponade" in prior-CABG patients.[12][19]
  • Pitfalls:
    • Reversing heparin with a wire, balloon, or stent still across the lesion.[33]
    • Giving protamine before draining a hemodynamically significant effusion.[30]
    • Never imaging the distal vessel after CTO or hydrophilic-wire work.[11]
    • Single-catheter covered stent delivery in an unstable patient or tortuous vessel instead of ping-pong or BAD.[11][27]
    • Treating an epicardial collateral perforation from only one direction.[12]
    • Forgetting to stop a GP IIb/IIIa infusion at the moment of perforation.[11]
    • Discharging early after apparent sealing despite the risk of delayed tamponade.[21]

Areas of Uncertainty

  • No randomized trials and no dedicated society guideline for CAP management.[12]
  • Covered stent comparisons (PTFE vs polyurethane vs pericardial) are observational; a randomized trial is considered infeasible.[25]
  • Fat vs coil embolization for distal perforation has not been compared in a controlled study.[12]
  • Optimal DAPT duration after covered stent and optimal cath-lab protamine dosing are not standardized.[39][30]
  • Existence of a long-term mortality "legacy effect" remains debated.[40][41]

References

  1. ↑ 1.0 1.1 1.2 1.3 Shimony A, Joseph L, Mottillo S, Eisenberg MJ (2011). "Coronary artery perforation during percutaneous coronary intervention: a systematic review and meta-analysis". Can J Cardiol. 27 (6): 843–50. doi:10.1016/j.cjca.2011.04.014.
  2. ↑ 2.0 2.1 2.2 2.3 2.4 2.5 2.6 2.7 Nairooz R, Parzynski CS, Curtis JP; et al. (2020). "Contemporary trends, predictors and outcomes of perforation during percutaneous coronary intervention (from the NCDR Cath PCI Registry)". Am J Cardiol. 130: 37–45. doi:10.1016/j.amjcard.2020.06.014.
  3. ↑ 3.0 3.1 3.2 3.3 3.4 Kinnaird T, Kwok CS, Kontopantelis E; et al. (2016). "Incidence, determinants, and outcomes of coronary perforation during percutaneous coronary intervention in the United Kingdom between 2006 and 2013: an analysis of 527 121 cases from the British Cardiovascular Intervention Society database". Circ Cardiovasc Interv. 9 (8): e003449. doi:10.1161/CIRCINTERVENTIONS.115.003449.
  4. ↑ Ford TJ, Adamson C, Morrow AJ; et al. (2022). "Coronary artery perforations: Glasgow Natural History Study of Covered Stent Coronary Interventions (GNOCCI) study". J Am Heart Assoc. 11 (19): e024492. doi:10.1161/JAHA.121.024492.
  5. ↑ 5.0 5.1 5.2 Kostantinis S, Simsek B, Karacsonyi J; et al. (2022). "Incidence, mechanisms, treatment, and outcomes of coronary artery perforation during chronic total occlusion percutaneous coronary intervention". Am J Cardiol. 182: 17–24. doi:10.1016/j.amjcard.2022.07.004.
  6. ↑ 6.0 6.1 6.2 6.3 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. doi:10.1161/01.cir.90.6.2725. PMID 7994814.
  7. ↑ 7.0 7.1 7.2 Shaukat A, Tajti P, Sandoval Y; et al. (2019). "Incidence, predictors, management and outcomes of coronary perforations". Catheter Cardiovasc Interv. 93 (1): 48–56. doi:10.1002/ccd.27706.
  8. ↑ Dehmer GJ, Badhwar V, Bermudez EA; et al. (2020). "2020 AHA/ACC key data elements and definitions for coronary revascularization: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Data Standards". J Am Coll Cardiol. 75 (16): 1975–2088. doi:10.1016/j.jacc.2020.02.010.
  9. ↑ 9.0 9.1 9.2 9.3 9.4 Majeed H, Blankenship JC (2023). "Ellis type 4 coronary artery perforation during percutaneous coronary intervention: case series and review". Catheter Cardiovasc Interv. 102 (7): 1252–1258. doi:10.1002/ccd.30873.
  10. ↑ 10.0 10.1 10.2 10.3 Cerrato E, Pavani M, Barbero U; et al. (2021). "Incidence, management, immediate and long-term outcome of guidewire and device related grade III coronary perforations (from G3CAP - Cardiogroup VI Registry)". Am J Cardiol. 143: 37–45. doi:10.1016/j.amjcard.2020.12.041.
  11. ↑ 11.00 11.01 11.02 11.03 11.04 11.05 11.06 11.07 11.08 11.09 11.10 11.11 11.12 11.13 11.14 11.15 11.16 11.17 11.18 11.19 11.20 11.21 11.22 Giannini F, Candilio L, Mitomo S; et al. (2018). "A practical approach to the management of complications during percutaneous coronary intervention". JACC Cardiovasc Interv. 11 (18): 1797–1810. doi:10.1016/j.jcin.2018.05.052.
  12. ↑ 12.00 12.01 12.02 12.03 12.04 12.05 12.06 12.07 12.08 12.09 12.10 Xenogiannis I, Brilakis ES (2019). "Advances in the treatment of coronary perforations". Catheter Cardiovasc Interv. 93 (5): 921–922. doi:10.1002/ccd.28205. PMID 30790440.
  13. ↑ 13.0 13.1 Caixeta A, Oliveira MDP, Dangas GD. Coronary artery dissections, perforations, and the no-reflow phenomenon. In: Interventional Cardiology. 2022.
  14. ↑ 14.0 14.1 14.2 Parsh J, Seth M, Green J; et al. (2017). "Coronary artery perforations after contemporary percutaneous coronary interventions: evaluation of incidence, risk factors, outcomes, and predictors of mortality". Catheter Cardiovasc Interv. 89 (6): 966–973. doi:10.1002/ccd.26917.
  15. ↑ 15.0 15.1 15.2 15.3 15.4 15.5 Kostantinis S, Simsek B, Karacsonyi J; et al. (2023). "Development and validation of a scoring system for predicting clinical coronary artery perforation during percutaneous coronary intervention of chronic total occlusions: the PROGRESS-CTO perforation score". EuroIntervention. 18 (12): 1022–1030. doi:10.4244/EIJ-D-22-00593. PMID 36281650 Check |pmid= value (help).
  16. ↑ 16.0 16.1 Simsek B, Tajti P, Carlino M; et al. (2023). "External validation of the PROGRESS-CTO perforation risk score: individual patient data pooled analysis of three registries". Catheter Cardiovasc Interv. doi:10.1002/ccd.30551. PMID 36617391 Check |pmid= value (help).
  17. ↑ 17.0 17.1 17.2 Hirai T, Grantham JA, Sapontis J; et al. (2022). "Development and validation of a prediction model for angiographic perforation during chronic total occlusion percutaneous coronary intervention: OPEN-CLEAN perforation score". Catheter Cardiovasc Interv. 99 (2): 280–285. doi:10.1002/ccd.29466. PMID 33438824 Check |pmid= value (help).
  18. ↑ Simsek B, Carlino M, Ojeda S; et al. (2023). "Validation of the OPEN-CLEAN chronic total occlusion percutaneous coronary intervention perforation score in a multicenter registry". Am J Cardiol. 188: 30–35. doi:10.1016/j.amjcard.2022.11.023. PMID 36462272 Check |pmid= value (help).
  19. ↑ 19.0 19.1 19.2 19.3 Tiwana J, Kearney KE, Lombardi WL, Azzalini L (2024). "Challenges in the diagnosis and management of dry tamponade". Catheter Cardiovasc Interv. 104 (6): 1228–1240. doi:10.1002/ccd.31241.
  20. ↑ 20.0 20.1 Surdacki MA, Major M, Chyrchel M; et al. (2020). "Urgent pericardiocentesis is more frequently needed after left circumflex coronary artery perforation". J Clin Med. 9 (9): 3043. doi:10.3390/jcm9093043. PMID 32967327 Check |pmid= value (help).
  21. ↑ 21.0 21.1 21.2 Fejka M, Dixon SR, Safian RD; et al. (2002). "Diagnosis, management, and clinical outcome of cardiac tamponade complicating percutaneous coronary intervention". Am J Cardiol. 90 (11): 1183–6. doi:10.1016/s0002-9149(02)02831-x. PMID 12450595.
  22. ↑ Claessen BE, Mehran R (2019). "Hope for the best, prepare for the worst: how to manage coronary perforations". Catheter Cardiovasc Interv. 93 (4): E255–E256. doi:10.1002/ccd.28055.
  23. ↑ Voelker R (2018). "Device approved to seal coronary artery perforations". JAMA. 320 (15): 1528. doi:10.1001/jama.2018.15037.
  24. ↑ Kandzari DE, Birkemeyer R (2019). "PK Papyrus covered stent: device description and early experience for the treatment of coronary artery perforations". Catheter Cardiovasc Interv. 94 (4): 564–568. doi:10.1002/ccd.28306.
  25. ↑ 25.0 25.1 25.2 Nagaraja V, Schwarz K, Moss S, Kwok CS, Gunning M (2020). "Outcomes of patients who undergo percutaneous coronary intervention with covered stents for coronary perforation: a systematic review and pooled analysis of data". Catheter Cardiovasc Interv. 96 (7): 1360–1366. doi:10.1002/ccd.28646.
  26. ↑ Patel NJ, Heuser RR (2019). "Covered stents: a 25-year odyssey". Catheter Cardiovasc Interv. 93 (3): E189–E190. doi:10.1002/ccd.28006.
  27. ↑ 27.0 27.1 27.2 Sanz Sanchez J, Garbo R, Gagnor A; et al. (2021). "Management and outcomes of coronary artery perforations treated with the block and deliver technique". Catheter Cardiovasc Interv. 98 (2): 238–245. doi:10.1002/ccd.29241.
  28. ↑ Cerrato E, Piedimonte G, Franzino M; et al. (2025). "Contemporary use of coils during percutaneous coronary intervention: insights from the multicenter COILSEAL registry". Catheter Cardiovasc Interv. 106 (7): 3888–3898. doi:10.1002/ccd.70233. PMID 41121637 Check |pmid= value (help).
  29. ↑ Scarparo P, Agostoni P, Goktekin O; et al. (2026). "Retrograde CTO PCI via epicardial collaterals: techniques, tools, and risk mitigation". JACC Cardiovasc Interv. 19 (14): 1847–1863. doi:10.1016/j.jcin.2026.05.022.
  30. ↑ 30.0 30.1 30.2 30.3 30.4 30.5 Danek BA, Kearney KE, Chung CJ; et al. (2023). "The contemporary role of protamine in the cardiac catheterization laboratory". Catheter Cardiovasc Interv. 102 (1): 111–120. doi:10.1002/ccd.30679.
  31. ↑ U.S. Food and Drug Administration. Protamine sulfate prescribing information. Updated 2025-04-29.
  32. ↑ Garcia DA, Baglin TP, Weitz JI, Samama MM (2012). "Parenteral anticoagulants: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines". Chest. 141 (2 Suppl): e24S–e43S. doi:10.1378/chest.11-2291.
  33. ↑ 33.0 33.1 Sawayama Y, Sasaki K, Taninobu N; et al. (2025). "Heparin reversal for coronary artery perforation". Catheter Cardiovasc Interv. 105 (2): 464–474. doi:10.1002/ccd.31339.
  34. ↑ Kumbhani DJ, Gibson CM, Kinlay S; et al. (2026). "Antiplatelet therapy in the management of atherosclerotic cardiovascular disease: 2026 ACC scientific statement: a report of the American College of Cardiology". J Am Coll Cardiol. doi:10.1016/j.jacc.2026.05.037.
  35. ↑ Mutlu D, Rempakos A, Alexandrou M; et al. (2024). "Emergency coronary artery bypass surgery after chronic total occlusion percutaneous coronary intervention: insights from the PROGRESS-CTO registry". Int J Cardiol. 405: 131931. doi:10.1016/j.ijcard.2024.131931. PMID 38432608 Check |pmid= value (help).
  36. ↑ Al-Lamee R, Ielasi A, Latib A; et al. (2011). "Incidence, predictors, management, immediate and long-term outcomes following grade III coronary perforation". JACC Cardiovasc Interv. 4 (1): 87–95. doi:10.1016/j.jcin.2010.08.026.
  37. ↑ Al Mawed M, Vlachojannis M, Pula A, Gielen S (2023). "Delayed coronary perforation four days after percutaneous coronary intervention with subsequent cardiac tamponade: a case report". Catheter Cardiovasc Interv. 102 (6): 1061–1065. doi:10.1002/ccd.30861.
  38. ↑ Hanna EB (2022). "Percutaneous coronary interventions and complications, intra-aortic balloon pump, ventricular assist devices, and fractional flow reserve". Practical Cardiovascular Medicine (2nd ed.).
  39. ↑ 39.0 39.1 Wańha W, Januszek R, Kołodziejczak M; et al. (2021). "Procedural and 1-year outcomes following large vessel coronary artery perforation treated by covered stents implantation: multicentre CRACK registry". PLoS One. 16 (5): e0249698. doi:10.1371/journal.pone.0249698. PMID 33979357 Check |pmid= value (help).
  40. ↑ 40.0 40.1 Kinnaird T, Anderson R, Ossei-Gerning N; et al. (2017). "Legacy effect of coronary perforation complicating percutaneous coronary intervention for chronic total occlusive disease: an analysis of 26 807 cases from the British Cardiovascular Intervention Society database". Circ Cardiovasc Interv. 10 (5): e004642. doi:10.1161/CIRCINTERVENTIONS.116.004642.
  41. ↑ 41.0 41.1 Kuno T, Ohata T, Nakamaru R; et al. (2023). "Long-term outcomes of periprocedural coronary dissection and perforation for patients undergoing percutaneous coronary intervention in a Japanese multicenter registry". Sci Rep. 13 (1): 20318. doi:10.1038/s41598-023-47444-7.
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