Courtesy of Dr. Carlos Fava.

Coronary perforation (CP) is a very uncommon event (≈0.4%), associated with severe complications that entail risk of death. It has usually been related to patients with a history of myocardial revascularization surgery (MRS). However, this group usually presents lower rates of cardiac tamponade due to pericardial fibrosis caused by surgery.

This study analyzed 59,644 coronary angioplasties in patients who underwent MRS. These procedures had been performed from 2005 to 2013. In that period, coronary angioplasties in MRS increased (from 7.7% in 2005 to 10.2% in 2013), and the global incidence of CP was 0.52% (309 patients). The incidence of CP in 2005 was 0.32%, rising to 0.68% in 2013 (p = 0.001); no difference was observed between native vessels and grafts (0.51% vs. 0.71%).

Population characteristics were similar, except for the presence of stable angina, which was higher among patients with CP in native vessels. Over the years, there was a rise in age, the incidence of prior stroke, and chronic total occlusions (CTO).

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In-hospital complications were more frequent among patients with CP (14.2% vs. 3.6%; p < 0.001) and included Q-wave acute myocardial infarction (2.9% vs. 0.2%; p < 0.001), major bleeding (14% vs. 0.9%; p < 0.001), blood transfusion (3.7% vs. 0.2%; p < 0.001), renal failure (1.1% vs. 0.1%; p < 0.001), and death (10% vs. 1.1%; p <0.001). Cardiac tamponade, cardiogenic shock, emergency surgery, and access-site complications were more common among this group.

No difference was observed between native vessels and grafts as regards in-hospital mortality and 30-day mortality.

The group with CP experienced higher rates of 30-day and 1-year mortality, which were associated with a higher incidence of comorbidities (odds ratio: 1.35).

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Age, CTO, rotational atherectomy use, number of stents, hypertension, and female sex were independently associated with CP in native vessels; history of stroke, New York Heart Association class, and number of stents used were associated with CP in grafts.

Conclusion

CP is an uncommon event during coronary angioplasty in MRS, but it is closely associated with adverse clinical outcomes and higher rates of 12-month mortality.

Editorial

This study was witness to a significant global increase over the years in angioplasty in patients with a history of MRS, which was associated with more comorbidities and more complex lesions (fundamentally, more common CTO, longer lesions, and bifurcation lesions). This brought about an increase in the rates of CP. However, the analysis per year also showed a decrease in mortality due to more operator experience.

It is important to know that patients with a history of MRS experience more comorbidities and much more complex lesions than those who have not undergone surgery. In consequence, as interventional physicians, we must gather as much experience as possible before facing these challenges that, in time, will surely become more and more commonplace.

Original title: Coronary Perforation Complicating Percutaneous Coronary Intervention in Patients with a History of Coronary Artery Bypass Surgery. An Analysis of 309 Perforation Cases from the British Cardiovascular Intervention Society Database.

Reference: Tim Kinnaird et al. Circ Cardiovasc Interv 2017;10:e005581.