TCT: Perforations during PCI should not be dismissed

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PCI complicated by grade III coronary perforation is associated with complex lesions and high acute and long-term major adverse cardiac event (MACE) rates, according to research presented Sept. 22 at the annual Transcatheter Cardiovascular Therapeutics conference in Washington, D.C.

Grade III coronary perforation is a “rare but recognized complication” associated with PCI and linked with high mortality and morbidity, according to lead author and study presenter Rasha Al-Lamee, MD, from the interventional cardiology unit at San Raffaele Scientific Institute in Milan, Italy. “Grade III is the most serious form of perforation, and is associated with mortality rates of 7 to 44 percent,” he said.

Based on a review of the procedural records of 24,465 patients at two institutions from May 1993 to December 2009, 56 patients had PCI complicated by grade III coronary perforation.

The majority of treated lesions were complex: 44.6 percent were type B2, 51.8 were type C and 28.6 percent were chronic total occlusions. Also, 44.6 percent of the treated lesions were within the left anterior descending artery and 32.1 percent in a small vessel ( <2.5 mm). Glycoprotein IIb/IIIa inhibitors were administered in 17.9 percent of the patients.

The device causing perforation was an intracoronary balloon in 50 percent of the cases—53.6 percent were compliant and 46.4 percent were non-compliant—intracoronary guide-wire in 17.9 percent, rotablation in 3.6 percent and directional atherectomy in 3.6 percent.

Following perforation, immediate treatment and success rates, respectively, were prolonged balloon inflation, 58.9 percent and 54.5 percent; covered stent implantation, 46.4 percent and 84.6 percent; emergency CABG, 14.3 percent and 37.5 percent; and coil embolization, 1.8 percent and 100 percent.

According to Al-Lamee, multiple methods were required to achieve hemostasis in 39.3 percent of the patients.

During the procedures of the 56 patients, 19.6 percent required cardiopulmonary resuscitation (CPR) and 3.6 percent died. For in-hospital outcomes, which included 54 patients, 3.7 patients required CABG and 14.8 percent died.

The combined procedural and in-hospital MI rate was 42.9 percent, and MACE rate was 55.4 percent.

At clinical follow-up, which included 46 of the 56 patients (median 38.1 months), 4.3 percent had an MI, 4.3 percent required CABG and 15.2 percent died.

At angiographic follow-up, which included 56.5 percent of the 56 patients, the target lesion revascularization rate was 13 percent, target vessel revascularization rate was 19.6 percent and MACE rate was 41.3 percent.

Due to the high mortality and MACE rates, Al-Lamee cautioned against such perforations, especially when treating complex lesions.