In the stent era, coronary artery perforation (CAP) is the most serious complication and a leading cause of death from percutaneous coronary intervention (PCI). Although preventable to a great extent, perforations are inevitable in any high-volume center. Prompt recognition and treatment can make the difference between benign and fatal outcomes. The incidence of CAP varies with the complexity of disease under treatment and with the aggressiveness of individual operators. An operator who never experiences a perforation is probably underdilating lesions and underdeploying stents. The reported incidence varies from 0.2% to 0.6%.1-5 It is much higher when atheroablative devices are used.5 In a meta-analysis of nearly 200,000 PCIs, the pooled incidence was 0.43%.4 Although there is no good series reporting the effect of stenting on the incidence of perforation, routine stenting most likely increases the perforation rate.
The classification of Ellis and colleagues1 is generally accepted. In this classification, a grade I perforation is an extraluminal crater without extravasation (this might also be termed a pseudoaneurysm); a type II perforation is a pericardial or myocardial blush without contrast jet extravasation; and a type III perforation is an extravasation through a 1-mm or larger perforation. This classification correlates with prognosis. A fourth category is designated cavity spilling, in which the perforation empties into an anatomic cavity: right ventricle, left ventricle, coronary sinus, and so on (Fig. 61-1).
Grade III perforation from the left anterior descending (LAD) coronary artery to the right ventricle (RV) treated with reversal of anticoagulation. (A) Grade III perforation from mid-LAD to RV. Contrast in RV chamber. (B) Contrast seen in RV outflow track. (C) Twenty minutes after discontinuing bivalirudin anticoagulation and following 20-minute balloon occlusion, the perforation is almost sealed, but a small leak continues. (D) Twenty-five minutes after, only a tiny leak remains. (E) Thirty minute later, the perforation is completely sealed, but the LAD is occluded.
Small perforations can usually be solved by prolonged balloon inflations combined with reversal of anticoagulation. Large perforations require more sophisticated treatment. Perforations in vein grafts frequently resolve with simple measures. This is because scarring around vein grafts may be enough to limit extravasation.
Perforations in proximal arteries require treatments that will both resolve the perforation and preserve antegrade flow. Blocking antegrade flow can sometimes solve more distal perforations. The most practical way to treat perforation in previously occluded arteries is to reocclude the artery. Perforations involving bifurcations are much more difficult to solve, because it may be necessary to stop bleeding in 2 branches while preserving flow to both branches. Occluding flow is the best way to solve perforations of small branches.
Perforations caused by balloons are relatively easy to solve, ...