Coronary perforation during percutaneous transluminal coronary angioplasty (PTCA) occurs very rarely. However, with the recent availability of alternative devices that cut, tear, or ablate to improve luminal dimensions, perforations have been noted more frequently.1 Covered stents provide a physical barrier to seal perforated or ruptured large-vessel coronary arteries and reduce the risk of hemorrhage without the need for invasive surgery. We describe a case of a right coronary artery (RCA) perforation that was successfully treated using a polyurethane-coated (PK Papyrus) stent (Biotronik).
A 76-year-old man with a history of hypertension, hyperlipidemia, and coronary artery disease with a history of coronary artery bypass grafting (CABG) was seen as an outpatient with complaints of exertional chest pain that was relieved with nitroglycerin. The last echocardiogram from 6 years ago showed an ejection fraction of 55% and mildly hypertrophic left ventricle with normal relaxation. The patient underwent a nuclear stress test that showed a reversible moderate inferolateral ischemia in the territory of the distal left circumflex coronary artery with an ejection fraction of 68%. Compared to a stress test done 6 years ago, this area of ischemia was new. The patient was loaded with clopidogrel 300 mg once, then 75 mg daily, and then subsequently underwent a left heart catheterization (LHC). The LHC showed severe native coronary artery disease. The RCA was diffusely diseased and severely calcified (Figure 1). There was an 80% lesion in the proximal RCA, 90% in the mid to distal RCA, and 80% lesion in the distal RCA. Successful percutaneous coronary intervention of the 90% diffuse, severely calcified lesion of the RCA was done using rotational atherectomy (Figure 2). The ostial, proximal, and distal RCA were treated with drug-eluting stents and post dilated using a non-compliant balloon. There was a <1 mm perforation of the mid RCA (Figure 3) that was treated using a 3.5 mm x 20 mm PK Papyrus covered stent that sealed off the perforation (Figure 4). Post-intervention stenosis was 0% with TIMI-3 flow (Figure 5). Dual antiplatelet therapy was recommended for a minimum of 1 year. An echocardiogram was done after the procedure that showed a small pericardial effusion. Clinically, the patient complained of minimal pleuritic chest pain intermittently and was prescribed colchicine 6 mg twice a day for 5 days.
The incidence of coronary perforation has been reported to occur in approximately 0.2 to 0.6% of all percutaneous coronary interventional procedures and is highest among cases involving balloon and/or stent oversizing, guidewire damage, chronic total occlusion revascularization, or use of atherectomy or laser ablation.2 The incidence of coronary perforation may increase in the future, given the increasing complexity of attempted coronary lesions, such as chronic total occlusions, which carry a 4.8 to 8.8% risk for perforation.3 Clinical sequelae following coronary artery perforation include death, myocardial infarction, and cardiac tamponade. Due to the need for both immediate and sustained sealing of the perforation to prevent hemodynamic collapse, covered stents represent the most common method to treat the site of hemorrhage when initial conservative measures like prolonged balloon inflation fail. Some independent factors associated with 30-day mortality are advanced age, diabetes mellitus, renal dysfunction, the use of rotational atherectomy, the use of cutting balloons, higher lesion complexity, and glycoprotein IIb/IIIa inhibitor use.4 Covered stents are considered an effective bailout strategy for large vessel coronary perforation, especially with an Ellis type II–III coronary perforation that cannot be salvaged using prolonged balloon inflation.5 There are four types of coronary perforation: (a) large vessel; (b) distal vessel; (c) septal collateral; and (d) epicardial collateral perforation. The Ellis classification for coronary perforation includes three types (I, II, and III) according to severity (Figure 6). Implantation of a covered stent is the cornerstone of large vessel perforation treatment and can be used in some distal vessel perforations when embolization is not feasible. The first step in every perforation is to inflate a balloon proximally or at the site of perforation (blocking balloon) to minimize bleeding into the pericardium and decrease the risk for tamponade. In some cases, prolonged balloon inflation may lead to hemostasis, but if pericardial bleeding continues, definitive treatment may be needed, which usually consists of covered stents for large vessel perforations or coil embolization for the other perforation types. Until 2019, the only commercially available covered stent in the United States was the JoMed or Abbott Graftmaster, which consists of two layers of stainless steel stents with a polytetrafluoroethylene (PTFE) membrane in-between.5 PK Papyrus consists of a cobalt chromium stent covered by a single layer of polyurethane graft and is also significantly more deliverable than the Abbott Graftmaster. In a small, retrospective study of 61 coronary perforation patients,6 PK Papyrus was associated with shorter delivery time (8 vs 15 min, P=.001), lower incidence of pericardial effusion (41% vs 72%, P=.028), lower incidence of cardiac arrest (5% vs 26%, P=.045), higher procedural success (86% vs 69%, P=.216), and lower 12-month need for target vessel revascularization (21% vs 5%, P=.083), as compared with the Abbott Graftmaster. Prior studies suggest that the use of covered stents improves event-free survival, enabling a life-threatening situation to be managed without emergency surgery and with significantly reduced rates of mortality, cardiac tamponade, and major adverse cardiac events.7 The median time for stent delivery (8 vs 15 min, P=.001) and the occurrence of both pericardial effusion and cardiac arrest (41% vs 72%, P=.028; 5% vs 26%, P=.045, respectively) were significantly lower in patients treated with the PK Papyrus stent.8
Coronary perforation remains a rare but potentially catastrophic complication of percutaneous coronary intervention. Cases of coronary perforation that require implantation of a covered stent have significant mortality and a high major adverse cardiovascular event rate. The use of polyurethane-covered stents is associated with a lower incidence of cardiac tamponade, lower incidence of emergency pericardiocentesis, and lower incidence of emergency surgery.9
Disclosures: The authors report no conflicts of interest regarding the content herein.
The authors can be contacted via Monarch Shah, MD, at email@example.com
- 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. doi: 10.1161/01.cir.90.6.2725
- 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; 147: 140-145.
- Tajti P, Burke MN, Karmpaliotis D, et al. Update in the percutaneous management of coronary chronic total occlusions. JACC Cardiovasc Interv. 2018; 11: 615-625.
- Kinnaird T, Kwok CS, Kontopantelis E, et al. Incidence, determinants, and outcomes of coronary perforation during percutaneous coronary intervention in the United Kingdom between 2006 and 2013: an analysis of 527 121 cases from the British cardiovascular intervention society database. Circ Cardiovasc Interv. 2016; 9: e003449.
- Xenogiannis I, Brilakis ES. Advances in the treatment of coronary perforations. Catheter Cardiovasc Interv. 2019 Apr 1; 93(5): 921-922. doi: 10.1002/ccd.28205
- Hernández-Enríquez M, Lairez O, Campelo-Parada F, et al. Outcomes after use of covered stents to treat coronary artery perforations. Comparison of old and new-generation covered stents. J Interv Cardiol. 2018;1-7. doi: 10.1111/joic.12525
- Al-Lamee R, Ielasi A, Latib A, et al. Incidence, predictors, management, immediate and long-term outcomes following grade III coronary perforation. JACC Cardiovasc Interv. 2011; 4: 87-95.
- Kandzari DE, Birkemeyer R. PK Papyrus covered stent: device description and early experience for the treatment of coronary artery perforations. Catheter Cardiovasc Interv. 2019 Oct 1; 94(4): 564-568. doi: 10.1002/ccd.28306
- Nagaraja V, Schwarz K, Moss S, et al. Outcomes of patients who undergo percutaneous coronary intervention with covered stents for coronary perforation: A systematic review and pooled analysis of data. Catheter Cardiovasc Interv. 2020 Dec; 96(7): 1360-1366. doi: 10.1002/ccd.28646