Iatrogenic coronary artery perforation (CAP) is a rare complication in percutaneous coronary intervention (PCI) with an estimated incidence up to 3 % in primary PCI. It is associated with a 13-fold increase of in-hospital major adverse events and a 5-fold increase of 30-day mortality. Proposed clinical and procedural predictors of CAP are dependent on patient (increased age, female gender), vessel anatomy (tortuosity, calcification, small diameter) and procedure characteristics (rotational atherectomy, guide wire (GW), balloon size). The most life-threatening complication is pericardial tamponade (PT) which requires prompt diagnosis and treatment. We report 2 cases of CAP that were effectively treated through an algorithm.
Case description:
First case:
A 86-year-old female with mildly reduced left ventricular ejection fraction (LVEF) presented to our chest pain unit for acute coronary syndrome with non-ST-segment elevation myocardial infarction (NSTEMI). Coronary angiography (CA) showed 3-vessel disease with subtotal calcified occlusion of the proximal anterior descending artery (LAD) as culprit lesion (CL). A type II/III CAP with dissection and PT occurred during the intervention, which was managed by covered stents (CS) and emergency pericardiocentesis (EP). The patient was discharged in good clinical condition.
Second case:
A 81-year-old female, with NSTEMI and drug-eluting stent implantation into the LAD 1 week ago and preserved LVEF had recurrent severe angina with electrocardiogram changes. The CA showed in-stent occlusion of the LAD as CL. During difficult wiring using a GW with hydrophilic coating, a type V distal CAP without hemodynamically relevant PE occurred, which was managed with prolonged inflation of the balloon and subsequent intracoronary thrombin injection via an over-the-wire balloon in ping-pong technique . This patient was also discharged in good clinical condition.
Discussion and conclusion:
Management of CAP depends on its severity and type of perforation (Ellis and Muller class I to V). Once CAP is confirmed, the balloon should immediately be positioned at the perforation site even before EP. Management strategies include prolonged inflation of the balloon, CS implantation, reversal of anticoagulation and embolization of the distal vessel. In general, type I CAP often seals spontaneously and has no clinical consequences. Most of type II CAPs can also be managed by balloon inflation with additional EP and CS if required. Reversal of anticoagulation is controversially discussed. Type III CAP usually requires CS implantation and EP to prevent PT. Type V CAP are mostly caused by distal GW manipulation. Thus, vessel size and distal location often impede access with CS. Management includes balloon inflation at the PCI location followed by distal artery embolization in case of persistent leakage. For embolization, subcutaneous fat, thrombin, occlusive microcoils, polyvinyl alcohol, clotted autologous blood and beads have been used. In conclusion, using a dedicated algorithm may obviate the need for emergency cardiac surgery in CAP which may be only necessary in rare cases when catheter-based treatment fails.
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