Acknowledgements: Faisal Latif, MD, FACC, FSCAI; Konstantinos Dean Boudoulas, MD

Coronary artery perforation is a rare, but potentially life-threatening complication of percutaneous coronary intervention (PCI) that can lead to cardiac tamponade, myocardial infarction (MI), cardiogenic shock, cardiac arrest, and/or death. The incidence is between 0.1% and 3%, with the highest risk in PCI to chronic total occlusion.^{1, 2} Coronary artery perforations are classified by location (large vessel, distal vessel, and collateral perforations) and by severity (Ellis classification).^{3, 4, 5} In this Tip of the Month, we will discuss the management of distal coronary artery perforation.

Factors Related to Coronary Artery Perforation (Large and Distal Vessels)

 Anatomical^2,6

•  Heavy calcification
•  Severe tortuosity
•  Smaller diameter coronary artery
•  Mismatched proximal and distal segment
•  Chronic total occlusion

Procedural

•  Hydrophilic-coated, polymer jacketed, and stiff-tip guidewires (most common cause)⁶
•  Oversized balloons (>1:2 vessel diameter) and stents⁶
• High-pressure balloon inflation
• Stenting tapering or a small diameter vessel
• Atherectomy devices⁶

Evaluation/Diagnosis

Most distal coronary perforations are diagnosed by coronary angiography during PCI. However, distal vessel perforations can go unrecognized initially if they are subtle, especially if the shutters are used. Thus, longer image acquisition and panning to the distal vessels is necessary when there is suspicion for a perforation.

Echocardiography should be performed emergently when there is clinical suspicion of cardiac tamponade. Hemodynamic compromise due to distal perforations can present as acute shortness of breath, hypotension, unexplained tachycardia, and/or recurrent or persistent chest pain. Serial echocardiography to monitor progression of pericardial effusion is necessary if an initial conservative approach is planned. 

In case of PCI for chronic total occlusion, collateral flow can result in persistent leaking from a distal vessel perforation and should be carefully assessed via retrograde angiography.

Management

The management of distal perforations are immediate hemodynamic stabilization and sealing of the perforation.

General Approaches

1. Provide hemodynamic stabilization/support:
   • Maintain adequate blood pressure and volume support with intravenous fluids, blood transfusion, auto transfusion, vasopressors, or atropine if bradycardia happens. 
   • Call for help (echocardiography sonographer, surgeon, anesthesiologist).
   • Prepare for an urgent pericardiocentesis in the setting of a cardiac tamponade. 
   • Provide percutaneous hemodynamic support (intra-aortic balloon pump, Impella) for shock. 
2. Stop antiplatelets and anticoagulants, as appropriate
3. Consider the reversal of anticoagulation with protamine once all equipment is removed from the coronary artery.

Specific Approaches

1. Balloon tamponade: Like all coronary perforations, the first step in the management of distal perforations is low-pressure prolonged balloon inflation with a balloon sized 1:1 to the target vessel proximal to the site of perforation.⁶ A second guidewire and microcatheter can be advanced alongside the balloon to allow definitive treatment of the perforation (block and deliver technique).
2. Additional common modalities used to treat distal perforations are included in Table 1.

Table 1

Figure 1 outlines the step-by-step approach of the management of a distal coronary perforation.

Figure 1^9,10

Conclusion

Coronary perforation is a rare, yet life-threatening complication of PCI with high mortality and morbidity if not recognized and treated immediately, especially for larger perforations. The most common cause of distal vessel perforation is related to guidewires. Prevention is the key, so distal wire position should be constantly monitored during PCI. Hydrophilic and heavy-tip wires should be exchanged for less-traumatic tip wires as soon as possible. Early diagnosis, appropriate interventions, monitoring, and escalation of treatment are the key to successful outcomes. 

References

1. Doll JA, Nikolsky E, Stone GW, et al. Outcomes of patients with coronary artery perforation complicating percutaneous coronary intervention and correlations with the type of adjunctive antithrombotic therapy: pooled analysis from REPLACE-2, ACUITY, and HORIZONS-AMI trials. J Interv Cardiol. 2009 Oct;22(5):453–9. 
2. Shimony A, Joseph L, Mottillo S, et al. Coronary artery perforation during percutaneous coronary intervention: a systematic review and meta-analysis. Can J Cardiol. 2011 Nov–Dec;27(6):843–50.
3. Ybarra LF, Rinfret S, Brilakis ES, et al. Definitions and Clinical Trial Design Principles for Coronary Artery Chronic Total Occlusion Therapies: CTO-ARC Consensus Recommendations. Circulation. 2021 Feb 2;143(5):479–500.
4. Ellis SG, Ajluni S, Arnold AZ, et al. Increased coronary perforation in the new device era. Incidence, classification, management, and outcome. Circulation. 1994 Dec;90(6):2725–30.
5. Shaukat A, Tajti P, Sandoval Y, et al. Incidence, predictors, management and outcomes of coronary perforations. Catheter Cardiovasc Interv. 2019 Jan 1;93(1):48–56. 
6. Lemmert ME, van Bommel RJ, Diletti R, et al. Clinical Characteristics and Management of Coronary Artery Perforations: A Single-Center 11-Year Experience and Practical Overview. J Am Heart Assoc. 2017 Sep 22;6(9):e007049. 
7. Shemisa K, Karatasakis A, Brilakis ES. Management of guidewire-induced distal coronary perforation using autologous fat particles versus coil embolization. Catheter Cardiovasc Interv. 2017 Feb 1;89(2):253–258. 
8. Nairooz R, Parzynski CS, Curtis JP, et al. Contemporary Trends, Predictors and Outcomes of Perforation During Percutaneous Coronary Intervention (From the NCDR Cath PCI Registry). Am J Cardiol. 2020 Sep 1;130:37–45. 
9. Emmanouil S. Brilakis, Manual of Percutaneous Coronary Interventions: A Step-by-Step Approach (London: Academic Press, 2021).
10. Jacob D, Savage MP, Fischman DL. Novel Approaches to Coronary Perforations: Everything But the Kitchen Sink. JACC Case Rep. 2022 Feb 2;4(3):142–144.