A coronary perforation is a rare but frightening event in the cardiac cath lab. Unfortunately, despite a large experience, coronary perforation can occur even in the best of hands. In light of a recent case in our lab, the fortuitous publications of two excellent articles on the management and outcomes of coronary perforation1,2 and some active discussions in our cath conference, we thought it would be worthwhile to address the topic for the CLD readership.
A 77-year-old man was being evaluated for a new cardiomyopathy (ejection fraction 20%). He had a history of an ascending aortic aneurysm, a permanent pacemaker, stage III kidney disease, atrial fibrillation, hypertension, hyperlipidemia, obstructive sleep apnea, and obesity. He was on appropriate medications for hypertension and atherosclerosis. His electrocardiogram (EKG) showed an atrioventricular paced rhythm. The chest x-ray showed cardiomegaly and mild basilar atelectasis, but was otherwise unremarkable.
Diagnostic coronary angiography (right radial approach) showed no significant left coronary artery (LCA) obstructions with diffuse distal left anterior descending (LAD) coronary artery disease. The right coronary artery (RCA) had an 80% calcified focal segment before the posterior descending artery (PDA) with diffuse disease distally (Figure 1). A fractional flow measurement was attempted, but the wire could not cross the tight stenosis. A Runthrough .014-inch workhorse guidewire (Terumo) was then used to perform balloon angioplasty. Due to tortuosity, calcification, and inadequate guide support, a Guideliner (Teleflex) was used to facilitate balloon passage, dilatation of the lesion, and placement of a stent. It had been observed that at some point the wire had migrated distally during the manipulations required to advance and remove the equipment. While the wire was withdrawn, it had exited the distal artery segment, as evident with faint distal contrast staining (Figure 2). The distal myocardial staining was noted as a wire perforation requiring attention, but the operator attempted to complete the stent postdilation prior to reversal of heparin and management of the perforation. This was performed while the patient’s chest was prepped and draped for possible pericardiocentesis. The patient’s blood pressure abruptly dropped to 70 mmHg systolic, and repeat angiography showed that the staining was more prominent (Figure 3) and the patient now had tamponade.
Steps to Manage Tamponade
We now have a patient with acute tamponade. What should we do first? The first step is to support the patient with rapid volume expansion. Rapidly begin IV normal saline infusion, i.e., “open up the fluids”.
Step 2, inflate a balloon in the distal part of the vessel to tamponade bleeding. At the same time, think about reversing the heparin with protamine. Following coronary balloon inflation, request pericardiocentesis equipment and make preparations (e.g., dopamine) to support the patient. At the same time, call the echocardiographer and notify cardiothoracic surgery (especially if the perforation is in a large coronary artery segment). It may be prudent to request help from another interventionalist in case more technical expertise is needed. For proximal vessel perforations, call for a covered stent to be available just in case the bleeding cannot be controlled by balloon tamponade. Remember that distal wire perforation does not need a covered stent to control bleeding. Most of the time removal of the wire and coronary balloon tamponade will control the leak.
Step 3, if the pericardial effusion produces significant hypotension, perform emergent pericardiocentesis. Under emergent conditions, there may not be time to wait for echocardiography to guide the operator. In this case, the operator must proceed with a blind approach. Many labs have an echocardiography machine in the lab and a quick image of the pericardial fluid can be helpful. After a pericardial drainage is achieved and blood pressure restored, recheck the vessel to determine the persistence of extravasation. Additional venous access is also helpful in case more fluids or blood transfusion is needed.
Fortunately, most distal wire perforations will seal by themselves when the vessel is depressurized by balloon tamponade. In our case, after pericardiocentesis treated the hypotension, the coronary balloon was inflated and the guidewire perforation had sealed (Figure 4). The patient’s blood pressure returned to normal, the vessel remained patent, and the patient was transferred to the ICU for monitoring. Pericardial drainage was less than 200 mL of serosanguineous fluid overnight. The pericardial drain was pulled the next day after echocardiography revealed no further pericardial effusion. The patient was discharged a day after that and has done well with no complaints.
A Brief Review of Coronary Perforation
There are 4 grades of perforation (Figure 5) as described by Ellis et al.3 Al-Lamee et al4 reported that grade 3 perforations occurred in 0.23% of patients, but carried a high in-hospital mortality of 18%. Guidewire perforations are more often of grades 1 and 2, with early recognitiation and treatment reducing the need for pericardiocentesis.
Recently, Dr. Shaukat and his group1 from Minneapolis reviewed their experience from 13,339 percutaneous coronary interventions from 2009 to 2016. Coronary perforation is truly rare, occurring in about 5/1000 cases (0.51%). Iatrogenic hemorrhagic pericardial tamponade following catheter-based intervention occurs at a rate of approximately 1.5 to 4.7% for valvuloplasty, 0.2 to 1% for radiofrequency ablation, 0.1 to 0.2% for electrophysiology studies, 0.03% for coronary angioplasty, 0.5% for cardiac biopsy, and 0.01% for diagnostic catheterization. Of importance, left ventricular perforation by guidewire during transcatheter aortic valve replacement (TAVR) has been reported to occur in approximately <2%, with pericardial tamponade leading to surgery in 7-14% of cases. For transseptal access for MitraClip (Abbott Vascular) procedures, the ACCESS-EU Mitra-Clip Registry study5 reports that pericardial tamponade occurred in 0.9% of cases. Left atrial appendage closure is associated with a 3.5% of perforation and tamponade.
Are Outcomes for Large Vessel Compared to Small Vessel Perforation Different?
Shaukat et al1 reported large vessel perforation (n=51) was three times more frequent than small vessel perforation (n=17). Large vessel perforations appeared to be related to stent inflation, whereas most distal perforations were due to guidewire exit, as shown in the current index case above. Those patients with highest risk for periprocedural perforations included those with the most complicated coronary anatomy and atherosclerotic substrate, and use of atheroablative devices. Patients with the highest risk of having coronary perforations during PCI are listed in Table 1. Gratifyingly, in their series1, only one patient with large vessel perforation required emergency surgery, but in-hospital mortality remained high for both large and small vessel perforations (8% and 12%, respectively). It is instructive that both large vessel and distal perforations carry the same or nearly same mortality. Thus, it is actually the acute and post-procedural management of patients with tamponade that determines outcomes. One take-home message was that early treatment appears to be associated with better survival.
Management of Cardiac Tamponade and Perforation
The management of pericardial tamponade and coronary perforation includes a number of different techniques, depending on the clinical circumstances. Fiocca et al2 listed the frequency of therapies in their experience. In-lab pericardiocentesis occurred in about 22%, while pericardiocentesis at any time during the admission occurred in 29%. Other methods included reversal of heparin in 43%, prolonged balloon inflation in 71%, covered stent in 28%, standard stent implantation in 14%, rare fat embolization and blood clot embolization at 2% each, coil embolization in 16%, and coronary artery bypass surgery in one patient (2%).
The rates of in-hospital death of 8% and death at one year of 14% were striking. In-hospital death was associated with use of a covered stent, suggesting the largest perforations were associated with the highest death rates. Those who had prolonged balloon inflation and heparin reversal had the fewest events.
Cardiac tamponade following coronary perforation was also associated with myocardial infarction in 18%, shock in 15%, heart failure in 10%, stroke in 4%, and recurrent tamponade in 26%, requiring transfusion in 25%, and bleeding within 72 hours in all patients. While this study2 is enlightening, the major limitation is the small sample size. Nonetheless, its lessons should be part of our routine knowledge base for complications in the cath lab.
Autologous Blood Reinfusion During Pericardiocentesis?
Our patient had significant intrapericardial bleeding, probably because of some delay in inflating the balloon to tamponade the artery. Pericardiocentesis drained out approximately 800 mL of blood. We were tempted to re-instill or auto-infuse this blood back into our patient’s vein. However, we were reluctant to perform autologous infusion, because of concerns that infusion of whole unfiltered blood had the potential to induce a coagulation abnormality, disseminated intravascular coagulation, possible infection, or hyperkalemia due to hemolysis. This issue was nicely addressed by Fiocca et al2, who described their experience in patients with iatrogenic hemorrhagic pericardial tamponade over a 10-year period and identified 30 consecutive patients in whom autologous blood reinfusion was used. Figure 6 demonstrates the connections that can be used for autologous infusion during pericardiocentesis. The authors concluded that autotransfusion of pericardial blood through a femoral vein is safe and effective, and can be used to support tamponade patients while decisions regarding definitive closure of the vessel leak are made.
The Bottom Line
The best method to avoid guidewire coronary perforation is to keep the distal guidewire in view at all times. Should staining be seen even faintly, take time to confirm whether there is a true perforation and be prepared to perform pericardiocentesis. Timely and correct management of cardiac tamponade is lifesaving. Figure 7 provides an algorithm useful to direct management of pericardial effusion. Re-infusion of the aspirated blood can minimize blood losses. Intravenous fluids and pressors are commonly administered to maintain systemic blood pressure while pericardiocentesis is being done. If pericardial bleeding continues after balloon inflation, use of a covered stent and fat or coil embolization are usually used for achieving hemostasis.
We hope this discussion will help your lab increase awareness of and vigilance for early, subtle signs of a coronary perforation.
Disclosures: Dr. Kern reports he is a consultant for Abiomed, Abbott Vascular, Philips Volcano, ACIST Medical, Opsens Inc., and Heartflow Inc. Dr. Seto reports no conflicts of interest regarding the content herein.
- Shaukat A, Tajti P, Sandoval Y, et al. Incidence, predictors, management and outcomes of coronary perforations. Catheter Cardiovasc Interv. 2019 Jan 1; 93(1): 48-56. doi: 10.1002/ccd.27706.
- Fiocca L, Cereda AF, Bernelli C, et al. Autologous blood reinfusion during iatrogenic acute hemorrhagic cardiac tamponade: Safety and feasibility in a cohort of 30 patients. Catheter Cardiovasc Interv. 2019 Jan 1; 93(1): E56-E62. doi: 10.1002/ccd.27784.
- Ellis SG, Ajluni S, Arnold AZ, et al. Increased coronary perforation in the new device era. Incidence, classification, management, and outcome. Circulation. 1994; 90: 2725-2730.
- 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 Jan; 4(1): 87-95. doi: 10.1016/j.jcin.2010.08.026.
- Maisano F, Franzen O, Baldus S, et al. Percutaneous mitral valve interventions in the real world: early and 1-year results from the ACCESS-EU, a prospective, multicenter, nonrandomized post-approval study of the MitraClip therapy in Europe. J Am Coll Cardiol. 2013 Sep 17; 62(12): 1052-1061.
- Brilakis ES, Best PJ, Elesber AA, et al. Incidence, retrieval methods, and outcomes of stent loss during percutaneous coronary intervention: a large single-center experience. Catheter Cardiovasc Interv. 2005; 66: 333-340.