1

Introduction

Coronary artery bypass graft surgery (CABG) for the treatment severe symptomatic coronary artery disease involves use of saphenous vein, radial artery or internal mamamary artery as conduits to supply blood to myocardium. Saphenous venous grafts (SVGs) are prone to degenerative atherosclerosis and eventually resulting late graft failure. Majority of symptomatic graft stenosis encountered in clinical practice are treated with percutaneous intervention (PCI) than repeat CABG to avoid risks of surgery; redo CABG has a mortality rate of 3%–7%, a peri-operative myocardial infarction rate of 3%–11% and less symptomatic benefit compared with the initial operation . However, increased utilization PCI of diseased graft increases the risk of graft perforation which fortunately is a rare but a life threatening emergency. The incidence of native coronary perforation is about 0.2%–0.6% . Although predictors of native artery perforation have been well studied and can result from wire, use of adjunct devices during PCI including rotational atherectomy, intravascular ultrasound, intervention on chronic total occluded vessel and calcific lesions. These adjunct devices often times avoided in vein graft interventions and hence predictors remain unknown coronary . Vessel perforations can result in life threatening cardiac tamponade, extensive hemorrhage, cardiogenic shock, cardiac arrest and vessel occlusion . Almost 50% of patients with perforation experience a major complication requiring emergency intervention, such as pericardiocentesis or emergent bypass surgery . The current treatment strategies include prolonged balloon inflation and reversal of anticoagulation, covering the perforated area with a covered stent, placing an uncovered stent within the first stent , an autologous vein covered stent or conservative management.

At present, the current data in literature on graft perforations are limited to a number of case reports and the predictive factors responsible for vessel perforation have not been validated. Moreover, the success rates of different treatment strategies have not been evaluated and at present no definitive guidelines state the optimum management strategy in such circumstances.

In this review we intend to identify factors contributing to graft perforations and also compare the efficacy of commonly reported management strategies.

2

Method

We performed a retrospective review of all cases of graft perforations published in PubMed/Medline from 1987 to 2015. We used the MESH words: “Graft perforation AND stent” in PubMed and included all case reports and studies pertaining to the topic. We collected a total of 25 case reports and included data from a case series involving 12 patients. Therefore, we had data on a total of 37 cases of graft perforations. We excluded studies in foreign language or those not translated into English.

We reviewed the case reports in terms of patient demographics, presenting symptoms, graft age, perforation classification, nature of the intervention resulting in perforation, the type of stents or balloons used for treatment and the short term outcomes.

2

Method

We performed a retrospective review of all cases of graft perforations published in PubMed/Medline from 1987 to 2015. We used the MESH words: “Graft perforation AND stent” in PubMed and included all case reports and studies pertaining to the topic. We collected a total of 25 case reports and included data from a case series involving 12 patients. Therefore, we had data on a total of 37 cases of graft perforations. We excluded studies in foreign language or those not translated into English.

We reviewed the case reports in terms of patient demographics, presenting symptoms, graft age, perforation classification, nature of the intervention resulting in perforation, the type of stents or balloons used for treatment and the short term outcomes.

3

Results

3.3

Procedure

Perforations were most commonly seen after stent placement (30%, n = 11) and after pre-dilation with balloon followed by stent placement (21%, n = 8). Among balloon angioplasty; which included a case of cutting balloon angioplasty (16%, n = 6) and post-dilation with balloon after stent placement (16%, n = 6). There were 2 cases of perforation from catheter placement (5%); one of which was after trans-luminal thrombus extraction catheter device insertion. In addition, there was one case of guide wire perforation (3%), one case following diagnostic angiogram (3%), and another following intravascular ultrasonography (3%) ( Fig. 1 ) ( Table 1 ).

Frequency of percutaneous interventions resulting in graft perforation.

Table 1

List of case reports of graft perforation highlighting the cause and treatment strategy of graft perforation.

Date of publication and author	Graft perforation caused by	Management strategy/stent information	Outcome
1987 Paul S. Teirstein et al.	4.2 mm Gruentzig S-style balloon dilated to 12 atm	Pericardial effusion drained by pericardiocentesis
1996 Colon PJ et al.	2.5 mm TEC catheter	-Prolonged inflation with 4.0 ACS RX perfusion balloon (Advanced Cardiovascular Systems, Inc., Temecula, CA) + -Vein graft stent patch prepared with 2 cm antecubital vein placed over 154 M Palmaz stent (Johnson & Johnson Interventional Systems Co., Warren, NJ) mounted on 4 × 20 mm Opta 5 balloon (Cordis Corporation, Miami, FL) to 16 atm	-Discharged day 3 -Doing well on 4 month follow up
1996 Nicholas W. Shammas et al.	-Pre-dilatation with 2.5-mm balloon -20-mm articulated biliary stent (Palmaz-Schatz stent, Johnson and Johnson, Warren, NJ) deployed at 12 atm	− 10-mm Palmaz stent deployed using a 4-mm noncompliant balloon (Total Cross, Scheider, Inc., Minneapolis, MN) at a maximum pressure of 12 mmHg for 30 minutes	Doing well on 2 month follow up
1999 Ronald Caputo et al.	-Predilation with 4 × 15 mm Quantum Ranger balloon (Scimed) + – 4 × 32 mm NIR stent (Scimed)	-Patient developed hypotension, IABP inserted -Prolonged balloon inflation with 4 × 20 mm Surpass perfusion balloon (Scimed) at 4 atm for 14 min + -Vein mounted stent prepared with ante-cubital vein and 4 × 16 mm NIR stent (Scimed) deployed to 16 atm	-Loculated pericardial effusion requiring surgical drainage -Discharged day 8
1999 Mohsen Sharifi et al.	-Predilation with a 3 × 15 mm Bonnie balloon catheter (Schneider, Glens Falls, NY) – 3 × 15 mm Multilink high-pressure stent (Advanced Cardiovascular Systems) deployed at 14 atm	-Pericardial tamponade -Graft perforation surgically repaired	Discharged day 7
2000 Remo Albiero et al.	-Pre-dilation with Ranger 1.5 mm balloon (Boston Scientific Scimed) + – 2.5 × 10 mm BioDivYsio SV stent (Biocompatibles Ltd., Surrey, UK)	-IV Protamine – 19 mm JoStent PTFE-covered stent (Jomed Implantate GMH, Rangendingen, Germany) mounted on Gemini 2.5 × 20 mm balloon deployed to 12 atm	-Left pleural effusion drain -Discharged day 5
2000 Remo Albiero et al.	3.0 × 18-mm AVE GFX stent (Arterial Vascular Engineering Canada Inc., British Columbia, Canada) implanted at 14 atm	-IV Protamine -Calipso 2.5 × 40 mm balloon (Bard Ireland Ltd., Galway, Ireland) inflated for 20 min to 6 atm + – 12 mm JoStent PTFE-covered stent mounted on 2.5 × 20 mm Activa balloon deployed to 12 atm	-Patient needed IABP -Discharged day 20
2000 Rosa-Ana Hernandez-Antolin et al.	5 × 13 mm Multi-Link Ultra stent (Advanced Cardiovascular Systems) post-dilated with 5 × 9 mm Chubby (Schneider, Glen Falls, New York) at 20 atm	-Patient developed hypotension and bradycardia – 5 × 9 mm Chubby (Schneider, Glen Falls, New York) inflated at 6 atm -Mounted stent: 26 mm Jostent (Jomed, Rangendingen, Germany) crimped on 4 × 3 mm Worldpass balloon at 10 atm	Discharged day 4. Asymptomatic on 3 months follow up
2000 Raviprasad G. Subraya et al.	-Pre-dilation with 3 × 20 mm Valor balloon (Cordis, Miami Lakes, FL) to 14 atm – 4 × 20 mm GR II Cook stent (Cook, Bloomington, IN) deployed at 9 atm	-4 × 20 mm GR II Cook stent (Cook, Bloomington, IN) deployed at 8 atm -Postdilated with 4 × 20 mm Thor balloon catheter (Cordis) at 12 atm for 30 s	Patient stable
2006 Worawut Tassanawiwat et al.	Cutting balloon angioplasty (Boston Scientific) with 3 × 10 mm device dilated at 14 atm	-Cardiac tamponade causing cardiac arrest and requiring pericardiocentesis -Two 3.5 × 19 mm Jostent PTFE-covered stents (Jomed) placed	Asymptomatic at 1 month follow up
2006 Zoe Astroulakis et al.	Direct stenting	2 covered stent	Discharged day 3
2008 Roberto Lorusso et al.	Direct stenting	-Cardiac tamponade and then cardiac arrest -Graft perforation surgically repaired	Discharged day 7. Doing well on 6 months follow up
2008 J.M. van Opstal et al.	-16 × 4 mm Liberte stent -Post-dilated at high pressure	-JOSTENT (Graftmaster, 19 × 3.5 mm) -Loculated pericardial effusion causing tamponade requiring surgery
2008 Peiman Jamshidi et al.	-Predilation with 2.5 × 20 mm balloon to 12 atm -Two 3.5 × 16 mm drug eluting stent deployed at 12 atm	-Two 3.5 × 15 mm covered stent implanted	Discharged day 5
2009 George Latsios et al.	-3 × 16 mm bare metal stent -Post-dilation with non-compliant 3X15 mm balloon at 24 atm	3 × 15 mm Jomed© PTFE covered stent
2010 DK Baruah et al.	Pre-dilation with Maverick 2.5 mm × 15 mm	4 × 31 mm Symbiot self-expandable covered stent (Boston Scientific, Natick, MA) deployed to 16 atm	Doing well at 3 yrs follow up
2010 Ben Glover et al.	-Pre-dilation with 4 mm balloon + – 4.5 × 24 mm Liberte stent (Boston Scientific, Natick, USA)	-IV Protamine -Prolonged balloon inflation + -2 Jostent (Abbott Laboratories, Illinois, USA) placed; 4.5 × 19 mm & 4 × 12 mm -Coil embolization of remaining graft leak	-Pericardial effusion resolved over 7 days -Doing well at 6 months follow up
2010 Adel El Hoseiny et al.	-3 × 20 mm Maverick balloon (Boston Scientific, Natick, MA) at 16 atm. -5 × 32 mm Liberte stent (Boston Scientific, Natick, MA) deployed to 18 atm.	-IV Protamine -Cardiac Magnetic Resonance (CMR) showed fistula between saphenous venous graft and right atrium -5 × 16 mm GraftMaster covered stent (Abbott Vascular) deployed to 17 atm to treat fistula
2011 Rohan S. Poulter et al.	Direct stenting	-Covered stents (Jostent Graftmaster; Abbott Laboratories, Abbott Park, IL) -Mediastinal hematoma which compressed the main pulmonary artery attempted CT-guided percutaneous drainage resulted in hemodynamic instability. Hence, Procedure abandoned and managed conservatively	Discharge day 10
2012 Lyisoy et al.	Repeated pre-dilation with 3.5 × 20 mm balloon and then 4 × 20 mm balloon at 20 atm	-Two 3.5 × 24 mm stents -Cardiac tamponade managed conservatively	Discharged
2013 Dong Yi Chen et al.	Pre-dilation with Maverick 4.0 × 30 mm balloon (Boston Scientific) at 10 atm	-Patient developed hemoptysis -Prolonged inflation with Firestar 3 × 30 mm balloon at 4 atm -GraftMaster 3 × 16 mm stent (Abbott Vascular) -IV Protamine	Discharged day 16
2013 Jonathan D. Salcedo et al.	Diagnostic Angiography	-Managed conservatively	Discharged
2013 Kostantinos Marmagkiolis et al. (case series of 12 patients)	-Stent implantation (n = 5) -Stent postdilation (n = 3) -Lesion predilation (n = 1) -Aspiration catheter (n = 1) -Intravascular ultrasonography (n = 1) -Coronary guide wire (n = 1)	-Covered stent implantation (n = 5) Conservative management (n = 3) -Prolonged balloon inflation (n = 2) -Deaths due to cardiac tamponade (n = 2)	2 Deaths
2013 Antonios N. Pavlidis et al.	4.0 × 16 mm Everolimus-eluting stent (Promus Element, Boston Scientific) to 16 atm	− 4 × 26 polytetrafluoroethylene-covered stent (Jostent Graft master, Abbott) -Localized pericardial effusion managed conservatively	Discharged day 2
2015 Christian Assad-Kottner et al.	LIMA dissected during upper lobe resection	Dual catheter technique: Two guide catheters were parked in the LIMA ostium. The 6 Fr guide had a balloon catheter occluding LIMA flow. The 8F guide used to deliver 3 × 26 mm PTFE-covered stent (Jostent Graftmaster, Abbott Vascular, Santa Clara,CA)	Good angiographic result
2015 Surender Deora et al.	3.5 × 18 mm Xience Pro (Abbott Vascular, Santa Clara, CA) inflated to 14 atm	3 × 18 mm covered stent at 12 atmosphere (Jostent Graftmaster, Abbott Vascular, Santa Clara, CA)	Asymptomatic at 1 month follow up

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