Coronary perforation (CP) occurs in 2-8% of percutaneous coronary interventions.1-3 It is a rare but potentially fatal complication, should tamponade occur. The diagnosis is easily made by the extravasation of contrast agent from the damaged vessel during angiography. However, distal perforation caused by an angioplasty guide can be misdiagnosed during the procedure and not be suspected until more severe complications develop.1 Initial signs include severe chest pain, tachycardia, and a drop in blood pressure. Bradycardia of vagal origin and ST segment changes may also occur.4
An 82-year-old female with type II diabetes mellitus, arterial hypertension, hypercholesterolemia, and a history of coronary angioplasty in the left coronary artery over 10 years prior was admitted to our department for a non ST-segment elevation myocardial infarction. An electrocardiogram (ECG) showed no repolarization disorders. Cardiac ultrasound showed hypokinesis of the inferior wall with preserved ejection fraction. The patient was premedicated with intravenous acetylsalicylic acid 250 mg, a loading dose of clopidogrel (75 mg orally), and 7000 IU of enoxaparin subcutaneously.
Radial access coronary angiography (Figures 1-2) revealed bi-arterial lesions, with an intermediate left descending coronary artery stenosis upstream of the stent and a very tight stenosis of the distal right coronary artery. Ad hoc angioplasty of the distal coronary artery was performed.
A 6 French (Fr) 100 cm MB1 Launcher coronary guide catheter (Medtronic) was positioned at the proximal right coronary artery. An .014-inch x 190 cm Hi-Torque Whisper MS Straight guidewire (Abbott Vascular) was positioned in the distal portion of the posterior interventricular artery. We started with predilatation of the distal right coronary stenosis with a 3.0 mm x 20 mm Trek balloon (Abbott Vascular), followed by placement of a 3.0 mm x 20 mm paclitaxel-eluting Taxus stent (Boston Scientific), straddling the distal right coronary artery and posterior interventricular artery. Finally, kissing balloon inflation was performed with a 3.0 mm x 15 mm intra-stent noncompliant balloon (NC Quantum Apex Monorail PTCA, Boston Scientific) and a 2.75 x 20 mm Trek balloon in the retroventricular artery. Final angiography showed stenosis-free, TIMI-3 flow in the distal right coronary artery and its two branches, with no thrombus or dissection (Figure 3).
Fifteen minutes later, the patient developed intense anginal pain. The ECG showed an earlier Pardee wave. Blood pressure was low at 60/40 mmHg. Urgent coronary angiography showed an excellent angioplasty result and the presence of an active coronary-pericardial breccia in the distal portion of the retroventricular artery (Figure 4). An echocardiogram confirmed the presence of a pericardial effusion of moderate abundance, but with no signs of typically associated tamponade.
Immediate filling with 1500 mL of colloids was performed, followed by transfusion of two red blood cell pellets and embolization of the retroventricular artery distortion. An .014-inch Whisper wire (Abbott Vascular) was positioned downstream to the perforation of the retroventricular artery, followed by prolonged inflation of a 1.5 mm x 1.5 mm Mini Trek balloon (2 inflations at 6 atmospheres [atm] for 10 minutes each, with an interval of 5 minutes between each inflation) immediately upstream of the breach in order to promote hemostasis. As the extravasation did not stop, following angiographic injections, we decided to perform a coronary embolization with placement of a microcoil. The perforation was occluded with an .018-inch 30 mm x 1 mm Tornado microcoil (Cook Medical) delivered through a 3 Fr .018-inch MicroFerret infusion catheter (Cook Medical) that was initially advanced over the Whisper wire and positioned in the distal retroventricular artery. The microcoil was positioned with a 2 mL saline flush through the delivery catheter. Extravasation ceased immediately and was confirmed on angiography 15 minutes later (Figure 5). At the end of procedure, the patient demonstrated good hemodynamic recovery. Ultrasound control showed the persistence of a pericardial effusion of moderate abundance associated with left pleural effusion. Pleuro-epicardial drainage was performed, removing 1200 mL of hematic fluid. The patient remained asymptomatic with good hemodynamic status and no further changes on ECG. An echocardiogram performed prior to patient discharge showed a minimal residual non-circumferential pericardial effusion of 6 mm next to the inferolateral wall, preserved ejection fraction, homogeneous kinetics, and a moderate, bilateral pleural effusion.
Coronary perforation is a rare complication of coronary angioplasty that can be potentially life-threatening. Immediate complications of coronary perforation include death (3-18%)1,5, tamponade (12-46%)6,7, malignant arrhythmias, and myocardial infarction (5-43%)2. Long-term complications include coronary aneurysm, pseudoaneurysm, or arteriovenous fistula formation.7
Coronary perforations can be classified into four types (Ellis classification) of increasing severity8 (Table 1). Type III perforations are associated with a worse prognosis, with a mortality of 6-44% for type III, and 0-6% for types I, II, and III cavity spilling (III CS).7,8
Guide perforation is the most common cause of coronary perforation, especially when using a rigid or hydrophilic guide such as the guide used in our case.9 The incidence of coronary perforation varies according to the treated artery, with the right coronary artery most affected by perforation, as was observed in our patient. Other risk factors associated with an increased risk of perforation have been described in the literature, and include female sex6,8, acute coronary syndrome without ST elevation3, and certain lesion features visible on angiography5, including eccentric lesions, long lesions (>10 mm), and chronic total occlusion10, as in our case.
Perforation by an angioplasty guide is the most common cause of coronary perforation, especially when hydrophilic guides are used.11 Indeed, distal perforation, the most common type of perforation, is frequently the result of unnoticed guide movement. Hydrophilic guides have an increased risk of perforation due to their low coefficient of friction and ease of distal migration.9
The therapeutic approach to perforation involves initial stabilization of the patient, followed by a determination of the size of the vessels at the site of the perforation.12,13 The therapy of choice for large vessels is traditionally either implantation of a covered stent, or urgent surgery with ligature and suture of the puncture, and often, coronary artery bypass.14 Small, distal vessels can be managed by prolonged balloon inflation and stopping anticoagulant therapy.15 Recent reports have also demonstrated the successful use of Gelfoam (Baxter) for distal embolization of small vessels.16,17
In our case, the management of coronary perforation required the sacrifice of the distal vessel by embolization with the placement of a microcoil. Despite hemodynamic instability, the patient was managed by non-surgical means, thus avoiding urgent surgery, which carries a significant risk of mortality. Interventional treatment was possible thanks to the distal nature of the perforation, which compromised the coronary flow only to a limited territory of the lower wall.
There are few reported cases describing the use of microcoils to treat coronary perforation.18,19 Microcoils have been used for occlusion of cerebral aneurysms, gastrointestinal bleeding, and other peripheral vascular therapeutic maneuvers.20 Microcoil use in the coronary arteries should be limited to perforations of small distal vessels due to their complete occlusion of the vessel and the risk of myocardial infarction. Primary complications from use include proximal delivery and occlusion of the major vessel. No major learning curve exists and no pre-training is required.18
The ideal method to manage coronary perforation is not well defined and will probably continue to evolve. The use of a microcoil was very effective in our patient, allowing the perforation to seal and restoring hemodynamics without major ischemic consequences.18
The presence of a congenital pleuro-pericardial window in our patient prevented the occurrence of cardiac tamponade despite coronary perforation, allowing blood to drain into the pleural cavity.21 A pleuro-pericardial window is a rare developmental anomaly resulting from defective partitioning of the pleuro-pericardial cavity during the fifth week of development.21 It is rarely symptomatic and especially in case of a wide or complete window, is without clinical consequence, but small windows can elicit serious consequences that may cause strangulation of cardiac structures, with complications including angina21, myocardial infarction22, ventricular arrhythmias23, syncope24, or sudden death25.
Patients with a large or complete pleuro-pericardial window usually do not require surgery unless complications occur.26 However, small pleuro-pericardial windows, which may cause herniation or entrapment of part of the heart, require surgical closure or enlargement.27 In our patient, the pleuro-pericardial window was wide enough to prevent the occurrence of tamponade and drain the pericardial effusion into the pleural cavity, so it was wide enough to not require surgery. Its presence was beneficial for the patient, as it allowed us to embolize in better hemodynamic conditions, without the need for urgent pericardial drainage prior to embolization. The shock observed was hypovolemic, which responded well to the vascular filling.
Coronary perforation is a serious and rare complication with a high risk of morbi-mortality despite immediate hemostasis. Predictive factors are related to the complexity of the lesions and the means used to treat them. Early recognition and management of coronary perforation is essential in order to preserve hemodynamic stability. Operators should be familiar with the various devices available for the management of distal and proximal coronary perforation. The treatment of a perforation is often multimodal. The deployment of a covered stent is often effective, but not always possible. Microcoil use is an effective alternative, especially for the treatment of a distal perforation.
1Interventional Cardiology; 2Cardiology Resident; 3Rhythmology; 4Department Head
Disclosure: The authors report no financial relationships or conflicts of interest regarding the content herein.
The authors can be contacted via Amine Bahloul, MD, at email@example.com, tel: 00 216 21 475 638.
- Al-Lamee R1, Ielasi A, Latib A, et al. Incidence, predictors, management, immediate and long-term outcomes following grade III coronary perforation. JACC Cardiovasc Interv. 2011 Jan; 4(1): 87-95.
- Fukutomi T, Suzuki T, Popma JJ, et al. Early and late clinical outcomes following coronary perforation in patients undergoing percutaneous coronary intervention. Circ J. 2002 Apr; 66(4): 349-356.
- Shimony A, Joseph L, Mottillo S, Eisenberg MJ. Coronary artery perforation during percutaneous coronary intervention: a systematic review and meta-analysis. Can J Cardiol. 2011 Nov-Dec; 27(6): 843-850.
- Klein LW. Coronary artery perforation during interventional procedures. Catheter Cardiovasc Interv. 2006 Nov; 68(5): 713-717.
- Witzke CF, Martin-Herrero F, Clarke SC, Pomerantzev E, Palacios IF. The changing pattern of coronary perforation during percutaneous coronary intervention in the new device era. J Invasive Cardiol. 2004 Jun; 16(6): 257-301.
- Fasseas P, Orford JL, Panetta CJ, et al. Incidence, correlates, management, and clinical outcome of coronary perforation: analysis of 16,298 procedures. Am Heart J. 2004 Jan; 147(1): 140-145.
- Gunning MG, Williams IL, Jewitt DE, et al. Coronary artery perforation during percutaneous intervention: incidence and outcome. Heart. 2002 Nov; 88(5): 495-498.
- 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): 2725-2730.
- Kiernan TJ, Yan BP, Ruggiero N, et al. Coronary artery perforations in the contemporary interventional era. J Interv Cardiol. 2009 Aug; 22(4): 350-353.
- Ramana RK, Arab D, Joyal D, et al. Coronary artery perforation during percutaneous coronary intervention: incidence and outcomes in the new interventional era. J Invasive Cardiol. 2005 Nov; 17(11): 603-605.
- Januszek R, Bartuś K, Litwinowicz R, et al. Coronary perforation of distal diagonal branch followed by prolonged recurrent cardiac tamponade finally resolved with pericardiotomy - the potential risk of hydrophilic guide-wires. Open Cardiovasc Med J. 2017 Jun 19; 11: 61-65.
- Briguori C, Nishida T, Anzuini A, et al. Emergency polytetrafluoroethylene-covered stent implantation to treat coronary ruptures. Circulation. 2000 Dec 19; 102(25): 3028-3031.
- Lansky AJ, Yang YM, Khan Y, et al. Treatment of coronary artery perforations complicating percutaneous coronary intervention with a polytetrafluoroethylene-covered stent graft. Am J Cardiol. 2006 Aug 1; 98(3): 370-374.
- Al-Mukhaini M, Panduranga P, Sulaiman K, et al. Coronary perforation and covered stents: An update and review. Heart Views. 2011 Apr; 12(2): 63-70.
- Ajluni SC, Glazier S, Blankenship L, et al. Perforations after percutaneous coronary interventions: clinical, angiographic, and therapeutic observations. Cathet Cardiovasc Diagn. 1994 Jul; 32(3): 206-212.
- Gaxiola E, Browne KF. Coronary artery perforation repair using microcoil embolization. Cathet Cardiovasc Diagn. 1998 Apr; 43(4): 474-476.
- Dixon SR, Webster MW, Ormiston JA, et al. Gelfoam embolization of a distal coronary artery guidewire perforation. Catheter Cardiovasc Interv. 2000 Feb; 49(2): 214-217.
- Banerjee S, Egdell R, Watkinson A, Greenbaum R. Coronary artery rupture treated with microcoil occlusion. Heart. 2001 Aug; 86(2): 187.
- Assali AR, Moustapha A, Sdringola S, Rihner M, Smalling RW. Successful treatment of coronary artery perforation in an abciximab-treated patient by microcoil embolization. Catheter Cardiovasc Interv. 2000 Dec; 51(4): 487-489.
- Bauer JR, Ray CE. Transcatheter arterial embolization in the trauma patient: a review. Semin Intervent Radiol. 2004 Mar; 21(1): 11-22.
- Sugiura Y, Matsusaka Y, Nemoto E, et al. Incidental finding of congenital pericardial and mediastinal pleural defect by pneumothorax in an adult. Radiography. 2015; 21(2): e81-e84.
- Brulotte S, Roy L, Larose E. Congenital absence of the pericardium presenting as acute myocardial necrosis. Can J Cardiol. 2007 Sep; 23(11): 909-912.
- Alonso A, Jensen PN, Lopez FL, et al. Association of sick sinus syndrome with incident cardiovascular disease and mortality: the Atherosclerosis Risk in Communities study and Cardiovascular Health Study. PLoS One. 2014 Oct 6; 9(10): e109662.
- Pernot C, Hoeffel JC, Henry M, Frisch R, Brauer B. Partial left pericardial defect with herniation of the left atrial appendage. Thorax. 1972 Mar; 27(2): 246-250.
- Uzün I, Büyük Y, Pakiş I, et al. Sudden death due to congenital pericardial defect: an autopsy case. Am J Forensic Med Pathol. 2008 Sep; 29(3): 242-244.
- Abbas AE, Appleton CP, Liu PT, Sweeney JP. Congenital absence of the pericardium: case presentation and review of literature. Int J Cardiol. 2005 Jan; 98(1): 21-25.
- Wang ZJ, Reddy GP, Gotway MB, et al. CT and MR imaging of pericardial disease. Radiographics. 2003 Oct; 23 Spec No: S167-S180.