Coronary artery perforation during percutaneous coronary intervention: incidence and outcomes in the new interventional era.

Background: Coronary artery perforation (CP) is a serious complication of percutaneous coronary intervention (PCI). We sought to define the incidence and outcome of CP given the advance in interventional techniques, devices and use of glycoprotein inhibitors (GP IIb/IIIa).

Methods: We retrospectively reviewed the records of patients who underwent PCI at our institution over a four-year period. The incidence of CP was derived from patient records and then confirmed by reviewing the angiogram. Perforations were classified as Type 1, 2, or 3, as previously defined.

Results: A total of 4,886 patients underwent PCI. Atherectomy devices were used in 329 patients and GP IIb/IIIa in 2,200 patients. Twenty-five CP were identified (0.5% incidence). Six were Type 1 (24%), 10 were Type 2 (40%), and 9 were Type 3 (36%). 13/25 (52%) of the CP were Type C Lesions, and 12/25 (48%) occurred in calcified vessels. All Type 1 perforations were caused by coronary wires and 4/6 CP occurred with the use of hydrophilic and extra stiff wires. Type 2 perforations were caused by coronary wires in 8/10 CP, and by stent deployment in 2/10. Two patients with Type 2 CP sustained a non-ST-elevation myocardial infarction. Type 3 perforations were caused by stent placement in 4/9 CP, 2/9 by atherectomy devices, and 3/9 by coronary wires. Four patients with Type 3 CP underwent pericardial drainage, 5 patients had a myocardial infarction and 2 patients died.

Conclusion: Type 1 and 2 perforations are predominately caused by hydrophilic and stiff wires and do not require pericardial drainage or surgical intervention. Type 3 perforations are more often associated with stent and device use. A majority of Type 3 perforations can be initially managed by percutaneous methods.