Coronary Perforations During PCI: Rare but Risky, BCIS Data Show
An analysis from the British Cardiovascular Intervention Society (BCIS) database is, for the first time, showing on a nationwide scale both the rarity and riskiness of perforation during PCI.
Perforation occurred in just a fraction of the nearly 530,000 cases performed in England and Wales between 2006 and 2013. But when it did happen, patients faced sharply increased risks of in-hospital adverse events like reinfarction, stroke, and bleeding as well as significantly higher odds of dying after 30 days, out through 5 years post-PCI.
Referring to perforation as “probably the worst complication we have to deal with,” lead author Tim Kinnaird, MD (University Hospital of Wales, Cardiff), told TCTMD it’s crucial that interventionalists be prepared to handle it effectively when it does occur.
Fivefold Rise in 30-Day Mortality
Kinnaird et al identified 1,762 coronary perforations recorded in the BCIS database, amounting to 0.33% of the 527,121 PCIs performed. Though not significant, there was a trend toward higher incidence from year to year over the 8-year study period, researchers said, suggesting it may relate to the increasing complex PCIs being done in an aging population.
Independent predictors of perforation included: age, previous CABG, left main occlusion, use of rotational atherectomy, and CTO. By contrast, male sex was associated with a lower risk of perforation.
In-hospital, patients who suffered a perforation had a 13-fold higher odds of MACE and 20-fold higher odds of bleeding than those who did not. The risks of reinfarction, emergency CABG, tamponade, and stroke also were elevated. Emergency surgery was needed for 3% of cases.
At 30 days, risk of dying was increased by nearly fivefold in patients who had suffered a perforation. The mortality burden persisted through 5 years, when patients with perforation had a 37% greater risk than those without the complication. Predictors of 30-day mortality in the perforation group included: age, diabetes, previous MI, renal disease, ventilator support, circulatory support, and glycoprotein IIb/IIIa inhibitor use.
Kinnaird said a key take-home message from the study is that while many predictors of perforation are patient-related—such as older age and female sex—much of the risk comes down to a particular PCI’s complexity, which can be hard to foresee. “Some of the time you know [perforation’s] coming, but I think a lot of the time you don’t,” he said. Once it happens, “there are a lot of things that can be done very rapidly to try and ameliorate the effects.”
For some operators who are more familiar with perforation, such as those frequently performing CTO PCI, “it isn’t so much of a panic,” Kinnard observed. For others, however, “having a clear plan in your mind and having the right tools and kit in the cath lab to fix the problem . . . are really, really important in managing what we can see from our data is a pretty catastrophic complication if it goes wrong,” he advised.
The specific tools vary according to whether the perforation was caused by the guidewire or the balloon. Pericardial drains are “very effective” and sometimes necessary, Kinnaird said, but carry the risk of comorbidity. Other options include using different kinds of material such as blood clot or adipose tissues to embolize the perforations, or placing metal coils, he said. “I think a familiarity with all of the different techniques for dealing with the different types of perforation is very important for operators dealing with complex patients.”
Perforation is so rare, in fact, that devices used to treat it can expire, Kinnaird said, joking that the most common end destination for the covered stents kept on hand in his cath lab is “the bin, because they go past the sell-by date.
“But you just have to have all those pieces of kit there, just in case,” he stressed.
Asked whether the incidence of perforation might continue to rise over time, particularly with the advent of bioresorable scaffolds (BRS), Kinnaird said that it is unknown but possible. “One of the things that [BRS] proponents have taught us is you have to be fairly aggressive in lesion preparation” with these new devices, he noted, adding, “Certainly in our data, bigger balloons and longer stents were associated with a higher incidence of perforation. . . . Time will tell.”
- 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;Epub ahead of print.
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- Kinnaird reports no conflicts of interest.