Coronary Artery Dissection and Perforation Complicating Percutaneous Coronary Intervention

Jason H. Rogers, MD; John M. Lasala, MD, PhD

Disclosures

J Invasive Cardiol. 2004;16(9) 

In This Article

Coronary Artery Perforation

Coronary perforation occurs when a dissection or intimal tear propagates outward sufficient to completely penetrate the arterial wall. A significant risk factor for perforation during PTCA is the balloon to artery ratio. In the report by Ajluni et al balloon perforations occurred from a measured balloon to artery ratio of 1.3 ± 0.3, which was significantly larger than the balloon to artery ratio of 1.0 ± 0.3 for other lesions in which perforation did not occur (p < 0.001).[3] Similarly, in a registry by Ellis et al, the balloon to artery ratio of those patients undergoing PTCA complicated by perforation was 1.19 ± 0.17 versus 0.92 ± 0.16 for those without perforation (p = 0.03).[4] This observation has been confirmed in another large randomized study in which a balloon to artery ratio > 1.1 was shown to result in a 2–3 fold increase in severe dissection leading to abrupt closure compared to a balloon/artery ratio < 1.1[34] In addition, balloon rupture, particularly those associated with pinhole leaks (as opposed to longitudinal tears), may create high pressure jets that increase the risk of dissection or perforation. (Figure 3) Many of the morphologic features associated with an increased incidence of perforation have also been implicated in an increased risk of dissection after balloon angioplasty.[34] Guidewire perforation may also occur as a result of stiffer, hydrophilic wires.[35]

Coronary artery dissection as a result of balloon perforation. (A) Initial cutting balloon inflation for treatment of diffuse in-stent restenosis of the right coronary artery. (B) Extensive coronary artery dissection propagating retrograde from site of cutting balloon inflation. Examination of the cutting balloon ex vivo revealed a pinhole perforation. This dissection was treated with prolonged balloon inflation with complete sealing of the intimal entry site.

Coronary artery dissection as a result of balloon perforation. (A) Initial cutting balloon inflation for treatment of diffuse in-stent restenosis of the right coronary artery. (B) Extensive coronary artery dissection propagating retrograde from site of cutting balloon inflation. Examination of the cutting balloon ex vivo revealed a pinhole perforation. This dissection was treated with prolonged balloon inflation with complete sealing of the intimal entry site.

Ellis et al evaluated a novel angiographic classification scheme for coronary artery perforations as a predictor of outcome.[4] In a multicenter registry of 12,900 PCIs, 62 (0.5%) perforations were reported and categorized as: Type I, extraluminal crater without extravasation; Type II, epicardial fat or myocardial blush without contrast jet extravasation; Type III, extravasation through frank (> 1 mm) perforation; or Type III "cavity spilling" (CS) referring to Type III perforations with contrast spilling directly into either the left ventricle, coronary sinus or other anatomic circulatory chamber. (Figures 4 and 5) Interestingly, the Ellis Type I perforation is angiographically identical to the previously described NHBLI Type C dissection, reinforcing the notion that a continuum exists between dissection and perforation. The use of devices intended to remove or ablate tissue were associated with higher perforation rates than PTCA alone (1.3% vs. 0.1%). Women and the elderly were also at increased relative risk. The investigators reported that Type I perforations were associated with no deaths or myocardial infarction, and tamponade in 8%. Type II perforations, when treated with a prolonged balloon inflation, resulted in no deaths and a low incidence of adverse sequelae (myocardial infarction in 14%, tamponade in 13%). Type III perforations were associated with the rapid development of cardiac tamponade (63%), the need for urgent bypass surgery (63%) and a high mortality (19%). Type III "cavity spilling" perforations, however, were associated with less catastrophic consequences (no deaths, myocardial infarction or tamponade resulted).

Ellis classification scheme for coronary artery perforations. Types I and II are "contained" perforations, whereas Type III is a "free" perforation with continuous extravasation of contrast. A more benign Type III "cavity spilling" perforation is also described in which contrast spills directly into an anatomic circulatory chamber.

An Ellis Type III perforation of the left anterior descending coronary artery at the site of a major diagonal. Arrow denotes the perforation site, and "jet" of contrast streaming into pericardial space is defined by arrowheads. A perfusion balloon was placed and the patient taken for emergent coronary artery repair and bypass.

In another large retrospective analysis, Ajluni et al reviewed 8,932 PCIs in which coronary artery perforation was reported in 35 (0.4%).[3] Perforations were classified angiographically as a: 1) free perforation, defined as free contrast extravasation into the pericardium (Ellis Type III); or 2) contained perforation, defined as a contained extraluminal blush or localized rounded crater of contrast extending outside the contrast-filled vascular lumen (Ellis Type I or II). Concurrent with prior reports, Ajluni et al. found that overall clinical outcomes were worse for patients with free perforations (tamponade 20%, CABG 60%, death 20%) than with contained perforations (tamponade 6%, CABG 24%, death 6%). The presence of complex (ACC/AHA type B2 or C) lesion morphology was more frequent in lesions associated with perforation, as were chronic total occlusions, bifurcation lesions, and moderate-severe angulation or tortuousity. Again, the use of devices intended to remove or ablate tissue were associated with higher perforation rates than PTCA alone. Two recent registries of cutting balloon angioplasty report a low incidence of perforation with this device.[36,37]

Both Ellis and Ajluni reported that in some cases of perforation, sudden cardiovascular collapse could ensue in the 24 hours after PCI from the development of delayed hemorrhagic pericardial effusions. Thus, vigilance and in-hospital observation is warranted for any patient with coronary perforation.

The largest consecutive series from a single center, the Washington Hospital Center, by Gruberg et al reported that out of 30,746 patients who underwent PCI during a 9-year period, 88 (0.29%) were complicated by coronary artery perforations.[6] Perforations were more common in complex lesions and those with moderate to severe vessel tortuousity. Although the severity of perforations was not classified angiographically as in the reports by Ellis and Ajluni, the overall morbidity and mortality associated with coronary perforation was comparable: tamponade 31%, myocardial infarction 35%, emergency surgery 39%, and death 10%.

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