Circulation, Vol 90, 2725-2730, Copyright © 1994 by American Heart Association
SG Ellis, S Ajluni, AZ Arnold, JJ Popma, JA Bittl, NL Eigler, MJ Cowley, RE Raymond, RD Safian and PL Whitlow
BACKGROUND: The incidence of coronary perforation using new percutaneous
revascularization techniques may be increased compared with PTCA. Still,
perforation is uncommonly reported, and the optimal management and expected
outcome remain unknown. The objectives of the study were to determine the
incidence of coronary perforation using balloon angioplasty (percutaneous
transluminal coronary angioplasty, PTCA) and new revascularization
techniques and to develop optimal strategies for its management based on
classification and outcome. METHODS AND RESULTS: Eleven sites with frequent
use of new revascularization devices and prospective coding of consecutive
procedures for coronary perforation during 1990 to 1991 contributed to a
perforation registry. Patients with perforation were matched by device with
an equal-sized cohort without perforation. Data were collected centrally,
and all procedural cineangiograms were reviewed at a core angiographic
laboratory. A classification scheme based on angiographic appearance of the
perforation (I, extraluminal crater without extravasation; II, pericardial
or myocardial blushing; III, perforation > or = 1-mm diameter with
contrast streaming; and cavity spilling) was evaluated as a predictor of
outcome and as a basis for management. Perforation was observed in 62 of
12,900 procedures reported (0.5%; 95% confidence interval, 0.4% to 0.6%),
more commonly with devices intended to remove or ablate tissue
(atherectomy, laser) than with PTCA (1.3%, 0.9% to 1.6% versus 0.1%, 0.1%
to 0.1%; P < .001). The perforation population was notable for its
advanced age (67 +/- 10 years) and high incidence of female sex (46%) (both
P < .001 compared with patients without perforation). Perforation could
be treated expectantly or with PTCA but without cardiac surgery in 85%,
90%, and 44% of class I, II, and III perforations, respectively. Class I
perforations (n = 13, 21%) were associated with death in none, myocardial
infarction in none, and tamponade in 8%. The incidences of these adverse
events were 0%, 14%, and 13% in class II perforations (n = 31, 50%) and
19%, 50%, and 63% in non-cavity spilling class III perforations,
respectively (n = 16, 26%). Two of the 15 instances of cardiac tamponade
(13%) were delayed, occurring within 24 hours after dismissal from the
catheterization laboratory. CONCLUSION: The incidence of perforation, while
low, is increased with new devices. Women and the elderly are at highest
risk. The clinical risk after perforation can be classified
angiographically, but even low-risk perforations occasionally have poor
clinical outcome. Patients should be observed for delayed cardiac tamponade
for at least 24 hours.
ARTICLES
Increased coronary perforation in the new device era. Incidence, classification, management, and outcome
Cleveland Clinic Foundation, OH 44195.
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