© Springer International Publishing Switzerland 2016
Stéphane Rinfret (ed.)Percutaneous Intervention for Coronary Chronic Total Occlusion10.1007/978-3-319-21563-1_1616. How to Prevent Perforation During CTO PCI
(1)
Department of Cardiology, Chicago Cardiology Institute, Schaumburg, IL, USA
Abstract
Coronary perforations remain a dreaded complication during percutaneous coronary intervention (PCI) for coronary chronic total occlusion (CTO). However, with the hybrid algorithm-driven approach, the incidence can be minimized; and if they do occur, the situation can be controlled and PCI completed in most cases.
The incidence of perforation in CTO PCI was found to be 2.9 % in a large meta-analysis of 18,061 patients from 65 studies. Most of these perforations were however self-limited and only 0.3 % resulted in cardiac tamponade. It should be noted that increasing experience and confidence along with more advanced techniques do not necessarily reduce the frequency of perforations due to more complex lesions attempted. However, experience results in better understanding of the situations that can result in improved outcomes related to the perforation.
Keywords
Coronary perforationPrevention of coronary perforationCoronary perforation and CTO PCIPredictors of coronary perforationClassification of coronary perforationCoronary perforations remain a dreaded complication during percutaneous coronary intervention (PCI) for coronary chronic total occlusion (CTO). However, with the hybrid algorithm-driven approach, the incidence can be minimized; and if they do occur, the situation can be controlled and PCI completed in most cases.
The incidence of perforation in CTO PCI was found to be 2.9 % in a large meta-analysis of 18,061 patients from 65 studies [1]. Most of these perforations were however self-limited and only 0.3 % resulted in cardiac tamponade. It should be noted that increasing experience and confidence along with more advanced techniques do not necessarily reduce the frequency of perforations due to more complex lesions attempted. However, experience results in better understanding of the situations that can result in dramatic outcomes related to the perforation.
Coronary perforation may result in one of the following potential consequences:
Tamponade
Myocardial hematoma, especially with septal branches
Coronary fistula into a cardiac vein, chamber or great vessels
Limited pericardial hematoma compressing a valve or chamber.
It should be noted that, many times, wire perforations are self-limited without any clinical consequences, especially in patients with previous surgery and resultant adherent pericardial space.
Predictors of Coronary Perforation
In a published review [2], Al-Mukhaini et al. evaluated the predictors of perforation. More specific to CTO, the following factors should be considered:
1.
Clinical factors: Advanced age, female sex, renal impairment, non ST-elevation myocardial infarction.
2.
Angiographic factors: Calcification, Type C lesions (all of which are CTOs), tortuosity, target lesions in the circumflex and right coronary arteries, long lesions.
3.
Technique-associated factors: Use of hydrophilic or stiff guidewires, atherectomy devices, increased balloon-to-artery ratio, high-pressure stent post-dilatation and cutting balloons.
Classification of Coronary Perforations
In 1994, Ellis et al. created a classification, which is still commonly used today:
Type I—Extra luminal crater without extravasation
Type II—Pericardial or myocardial blush without contrast jet extravasion
Type III—Extravasion through frank (>1 mm) perforation
Cavity Spilling—Perforation into an anatomic cavity or chamber [3].
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