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| {{SI}}
| | #redirect:[[PCI complications: vessel perforation]] |
| {{WikiDoc Cardiology Network Infobox}}
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| {{CMG}}<br/>
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| '''Associate Editors-In-Chief:''' Xin Yang, M.D.; Duane Pinto, M.D.; Brian C. Bigelow, M.D.
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| ==Background==
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| Coronary perforation occurs when a [[dissection]] or an [[intimal]] tear is so severe that it extends outward sufficiently to completely penetrate the arterial wall. It is an uncommon complication of [[PCI|coronary intervention]], with an incidence of 0.19%-0.58%<ref name="pmid16996872">{{cite journal |author=Javaid A, Buch AN, Satler LF, ''et al.'' |title=Management and outcomes of coronary artery perforation during percutaneous coronary intervention |journal=Am. J. Cardiol. |volume=98 |issue=7 |pages=911–4 |year=2006 |month=October |pmid=16996872 |doi=10.1016/j.amjcard.2006.04.032 |url=}}</ref><ref name="pmid14691432">{{cite journal |author=Fasseas P, Orford JL, Panetta CJ, ''et al.'' |title=Incidence, correlates, management, and clinical outcome of coronary perforation: analysis of 16,298 procedures |journal=Am. Heart J. |volume=147 |issue=1 |pages=140–5 |year=2004 |month=January |pmid=14691432 |doi= |url=}}</ref><ref name="pmid11246236">{{cite journal |author=Dippel EJ, Kereiakes DJ, Tramuta DA, ''et al.'' |title=Coronary perforation during percutaneous coronary intervention in the era of abciximab platelet glycoprotein IIb/IIIa blockade: an algorithm for percutaneous management |journal=Catheter Cardiovasc Interv |volume=52 |issue=3 |pages=279–86 |year=2001 |month=March |pmid=11246236 |doi=10.1002/ccd.1065 |url=}}</ref>, as noted among various studies. However, it is associated with significant [[morbidity]] and mortality. One study found a 12.6% incidence of [[acute myocardial infarction]], 11.6% incidence of [[cardiac tamponade]] and a mortality rate of 7.4%<ref name="pmid14691432">{{cite journal |author=Fasseas P, Orford JL, Panetta CJ, ''et al.'' |title=Incidence, correlates, management, and clinical outcome of coronary perforation: analysis of 16,298 procedures |journal=Am. Heart J. |volume=147 |issue=1 |pages=140–5 |year=2004 |month=January |pmid=14691432 |doi= |url=}}</ref>.
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| Associations with coronary perforation include:
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| * Balloon to artery ratio > 1.1
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| * Use of debulking procedure
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| * Complex coronary anatomy (i.e. [[calcified]] lesion, [[chronic total occlusion]], [[tortuosity]] of the vessel and ostial lesion)
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| * Stiff and [[hydrophilic]] wires
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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 other anatomic circulatory chamber
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| The Ellis Classification was evaluated as a predictor of certain outcomes and as a basis for management. Stratifying the outcomes by perforation type are summarized as follows<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>:
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| * '''Type I''' - No deaths or [[myocardial infarction]], [[tamponade]] incidence 8%
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| * '''Type II''' - No deaths, [[myocardial infarction]] incidence 14%, [[tamponade]] incidence 13%
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| * '''Type III''' - Mortality incidence 19%, cardiac [[tamponade]] incidence 63%, the need for urgent [[bypass surgery]] 63%
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| * '''Type III "cavity spilling" (CS)''' - No deaths, [[myocardial infarction]] or [[tamponade]], but sample limited in size
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| ==Goals of Treatment==
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| 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]].
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| ==Treatment==
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| Many different treatment options exist. First, the reversal of [[anticoatulation]] can be accomplished with [[Protamine]] if the patient is on [[heparin]] (guided by activated clotting time), or through [[platelet]] [[transfusions]] (4-10 units) if the patient was given [[abciximab]] or [[thienopyridine]].
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| 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]]. If there is continued evidence of perforation, use perfusion balloons if available to allow for prolonged inflation without inducing myocardial [[ischemia]].
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| [[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 timing between deflation of balloon and deployment of the stent, bilateral groin access with two guide catheters approach should be considered.
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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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