Coronary perforation is a potential complication of chronic total occlusion (CTO) percutaneous coronary intervention (PCI). We analyzed 2,097 CTO PCIs performed in 2,049 patients from 2012 to 2017. Patient age was 65 ± 10 years, 85% were men, and 36% had prior coronary artery bypass graft surgery. Technical and procedural success were 88% and 87%, respectively. A major periprocedural adverse cardiovascular event occurred in 2.6%. Coronary perforation occurred in 85 patients (4.1%); The frequency of Ellis class 1, 2, and 3 perforations was 21%, 26%, and 52%, respectively. Perforation occurred more frequently in older patients and those with previous coronary artery bypass graft surgery (61% vs 35%, p < 0.001). Cases with perforation were angiographically more complex (Multicenter CTO Registry in Japan score 3.0 ± 1.2 vs 2.5 ± 1.3, p < 0.001). Twelve patients (14%) with perforation experienced tamponade requiring pericardiocentesis. Patient age, previous PCI, right coronary artery target CTO, blunt or no stump, use of antegrade dissection re-entry, and the retrograde approach were associated with perforation. Adjusted odds ratio for periprocedural major periprocedural adverse cardiovascular events among patients with perforation was 15.04 (95% confidence interval 7.35 to 30.18). In conclusion, perforation occurs relatively infrequently in contemporary CTO PCI performed by experienced operators and is associated with baseline patient characteristics and angiographic complexity necessitating use of advanced crossing techniques. In most cases, perforations do not result in tamponade requiring pericardiocentesis, but they are associated with reduced technical and procedural success, higher periprocedural major adverse events, and reduced procedural efficiency.
Bibliographical noteFunding Information:
Dr. Karmpaliotis: speaker bureau, Abbott Vascular, Medtronic, and Boston Scientific. Dr. Alaswad: consultant for Boston Scientific, Abbott Vascular, and Terumo. Dr. Jaffer: consultant to Boston Scientific, Siemens, and Merck, nonfinancial research support from Abbott Vascular, research grant from National Institutes of Health (HLR01-108229). Dr. Yeh: Career Development Award (1K23HL118138) from the National Heart, Lung, and Blood Institute. Dr. Kandzari: research/grant support and consulting honoraria from Boston Scientific and Medtronic Cardiovascular, and research/grant support from Abbott. Dr. Lembo: speaker bureau: Medtronic; advisory board Abbott Vascular and Medtronic. Dr. Patel: speakers’ bureau for Astra Zeneca. Dr. Mahmud: clinical trial support from Boston Scientific, Corinudus, and Gilead; consultant for The Medicines Company; speakers’ bureau of Medtronic. Dr. Lombardi: equity with Bridgepoint Medical. Dr. Wyman: Honoraria/consulting/speaking fees from Boston Scientific, Abbott Vascular, and Asahi. Dr. Garcia: consulting fees from Medtronic Dr. Kirtane: Institutional research grants from Boston Scientific, Medtronic, Abbott Vascular, Abiomed, St. Jude Medical, Vascular Dynamics, Glaxo. Dr. Ali: grant support and consultant for St Jude Medical and InfraReDx. Dr. Parikh: speaker bureau: Abbot Vascular, Medtronic, CSI, BSc; advisory boards: Medtronic, Abbott Vascular, Philips. Dr. Rangan: research grants from InfraRedX and Spectranetics. Dr. Banerjee: research grants from Gilead and the Medicines Company; consultant/speaker honoraria from Covidien and Medtronic; ownership in MDCARE Global (spouse); intellectual property in HygeiaTel. Dr. Brilakis: consultant for Abbott Vascular, Asahi, Boston Scientific, Elsevier, Somahlution, St Jude Medical, and Terumo; research support from Boston Scientific and InfraRedx; spouse is employee of Medtronic. The remaining authors have no disclosures.