SOLACI | Latin American Society of Interventional Cardiology

Courtesy of Dr. Guillermo Migliaro.

Coronary perforation (CP) is a rare but serious complication of percutaneous coronary intervention (PCI) with an estimated incidence of 0.5%. Arterial blood entering the pericardium may cause a rapid elevation of intrapericardial pressure and collapse the right cavities (tamponade) creating hemodynamic compromise.

Historically, surgical drainage has been the standard treatment for this complication, but technological developments, such as drug eluting stents or coil embolization, among others, has allowed CP to be treated in the cath lab.

CP cases published so far are no more than 1.000 (the largest series has 124 cases). Given the small number of events per published series, it has not been possible to examine the real incidence of CP, its associated and predisposing factors, or the outcomes of CP interventions.

This study aims at answering these questions using the database of the British Society of Cardiovascular Interventions, including 527,121 PCI performed in England and Wales between 2006 and 2013. Data were collected prospectively. Multivariable analyzis and logistic regression of demographic variables were carried out in search of CP predictors and associated outcomes.

1,762 CP cases were reported, which results in 0.33% incidence. CP was more frequent among women and elderly patients, with higher number of comorbidities (hypertension, hypercholesterolemia, prior MI, peripheral heart disease and ventricular dysfunction).

Multivariable analyzis identified as CP predictors:

Age (OR 1.03; CI 95%,1.02-1.03; p<0.001)
Prior CABG (OR 1.44; CI 95%, 1.17-1.77; p<0.001).
Left main intervention (OR 1.54; CI 95%, 1.21-1.96; p<0.001).
Use of rotational atherectomy (OR 2.37; CI 95% 1.80-3.11; p<0.001).
Chronic occlusion intervention (OR 3.96; CI 95%, 3.28-4.78; p<0.001).

Factors associated with lower risk of CP were:

Male gender
Diabetes
Presence of shock
Use of cutting balloon.

As regards outcomes, in-hospital major cardiovascular events were more frequent in the group with CP (26% vs. 2% p<0.001). Also mortality at 30 days, one year and 5 years were higher in this group, as well as in-hospital non-cardiac events, such as major bleeding and stroke. 14% of patients with CP presented cardiac tamponade and 3% needed emergency surgery.

Mortality predictors at 30 days in patients with CP were:

Age
Patients with Diabetes Mellitus
Patients with prior MI
Patients with kidney failure with the need of life support that had undergone stenting and been prescribed IIbIIIa glycoprotein inhibitors.

Conclusion

Coronary perforation is a rare complication strongly associated to negative outcomes.

Editorial Comment

The present study reports the largest series of coronary perforation cases analyzed so far. Volume allows us to analyze factors associated to its presentation and outcomes. There is no question that it is essential to know these data, since the incidence of this complication will likely increase along with the number of procedures and, mainly, their complexity.

On the other hand, this study does not contemplate CP associated mechanisms (aggressive predilation, perforations related to guide wires, post dilation, etc.) or their severity. Neither does it analyze the intervention strategies involved, nor their impact on the final outcome.

Courtesy of Dr. Guillermo Migliaro. Hospital Alemán, Buenos Aires, Argentina.

Original Title: Incidence, Determinants and Outcomes of Coronary Perforation during Percutaneous Coronary Intervention in the United Kingdom Between 2006 and 2013. Analysis of 527121 Cases from the British Cardiovascular Intervention Society Database

Reference: Tim Kinnard et al. Circ Cardiovasc Interv. 2016 Aug;9(8). pii: e003449.