Chronic total occlusion percutaneous coronary intervention: managing perforation complications

ABSTRACT

Introduction

Coronary artery perforation (CAP) is an infrequent (<1%) complication of percutaneous coronary intervention (PCI), that can lead to dramatic consequences, including tamponade and death. The incidence of CAP is higher (4–9%) in chronic total occlusion (CTO) PCI due higher complexity of these lesions and the techniques used to recanalized them.

Areas covered

In this Expert Review, we discuss the specific features of CTO PCI predisposing to CAP. We also describe the typical procedural scenarios in which CAP can occur and provide a universal management algorithm. Currently available devices and techniques for CAP treatment are presented in detail. Finally, we discuss imaging support for diagnosis of pericardial effusion in CAP as well as medical and surgical management.

Expert Opinion

With increasing volumes and complexity of CTO PCI, the incidence of CAP is likely to rise. Adherence to good catheterization laboratory practices, availability of dedicated equipment to seal CAP, perform pericardiocentesis, and provide hemodynamic support, as well as adequate training, are pillars for the prevention and optimal management of CAP during CTO PCI.

KEYWORDS:

• Cardiac tamponade
• chronic total occlusion
• coronary artery perforation
• percutaneous coronary intervention
• complications
• covered stent
• coil
• embolization

Article Highlights

• CAP is an uncommon but potentially lethal complication of PCI.

• CTO PCI is associated with higher risk of CAP, which complicates 4-9% of all CTO PCI procedures.

• CAP in CTO PCI can occur in four scenarios: antegrade or retrograde wire exit; collateral channel perforation during the retrograde approach; perforation of the target vessel during lesion preparation, stenting, or stent optimization; and distal wire perforation.

• The first step in managing all types of CAP is proximal balloon inflation to stop bleeding into the pericardium. If bleeding does not resolve, subsequent management depends on perforation location: distal vessel perforations are usually treated with coil or fat embolization, and large vessel perforation with covered stent implantation. Tamponade with hemodynamic collapse mandates immediate pericardiocentesis, as well as mechanical circulatory support in selected cases. Surgical repair is rarely required.

• Comprehensive patient management, with early echocardiographic evaluation as well as activation of cardiac intensive care unit and cardiothoracic surgery teams, is warranted to improve patient outcomes.

Declaration of interest

L Azzalini reports consultant fees from Teleflex. E Briliakis reports consulting/speaker honoraria from Abbott Vascular, American Heart Association (associate editor Circulation), Amgen, Biotronik, Boston Scientific, Cardiovascular Innovations Foundation (Board of Directors), ControlRad, CSI, Ebix, Elsevier, GE Healthcare, InfraRedx, Medtronic, Siemens and Teleflex; he received research support from Regeneron and Siemens and is a shareholder of MHI Ventures.

Supplemental data

Supplemental data for this article can be accessed here.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.