Taishi Hirai1, William J Nicholson2, James Sapontis3, Adam C Salisbury1, Steven P Marso4, William Lombardi5, Dimitri Karmpaliotis6, Jeffrey Moses6, Ashish Pershad7, R Michael Wyman8, Anthony Spaedy9, Stephen Cook10, Parag Doshi11, Robert Federici12, Karen Nugent13, Kensey L Gosch13, John A Spertus1, J Aaron Grantham14. 1. Saint Luke's Mid America Heart Institute, Kansas City, Missouri; Department of Medicine, Division of Cardiology, University of Missouri Kansas City, Kansas City, Missouri. 2. York Hospital, York, Pennsylvania. 3. Monash Heart, Melbourne, Australia. 4. Research Medical Center, Kansas City, Missouri. 5. University of Washington, Seattle, Washington. 6. Columbia University, New York Presbyterian Hospital, New York, New York. 7. Banner University Medical Center, Phoenix, Arizona. 8. Torrance Medical Center, Torrance, California. 9. Boone County Hospital, Columbia, Missouri. 10. Peacehealth Sacred Heart Medical Center, Springfield, Oregon. 11. Alexian Brothers Medical Center, Chicago, Illinois. 12. Presbyterian Health System, Albuquerque, New Mexico. 13. Saint Luke's Mid America Heart Institute, Kansas City, Missouri. 14. Saint Luke's Mid America Heart Institute, Kansas City, Missouri; Department of Medicine, Division of Cardiology, University of Missouri Kansas City, Kansas City, Missouri. Electronic address: jgrantham@saint-lukes.org.
Abstract
OBJECTIVES: This study sought to describe the angiographic characteristics, strategy associated with perforation, and the management of perforation during chronic total occlusion percutaneous coronary intervention (CTO PCI). BACKGROUND: The incidence of perforation is higher during CTO PCI compared with non-CTO PCI and is reportedly highest among retrograde procedures. METHODS: Among 1,000 consecutive patients who underwent CTO PCI in a 12-center registry, 89 (8.9%) had core lab-adjudicated angiographic perforations. Clinical perforation was defined as any perforation requiring treatment. Major adverse cardiac events (MAEs) were defined as in-hospital death, cardiac tamponade, and pericardial effusion. RESULTS: Among the 89 perforations, 43 (48.3%) were clinically significant, and 46 (51.7%) were simply observed. MAE occurred in 25 (28.0%), and in-hospital death occurred in 9 (10.1%). Compared with nonclinical perforations, clinical perforations were larger in size, more often at a collateral location, had a high-risk shape, and less likely to cause staining or fast filling. Compared with perforations not associated with MAE, perforations associated with MAE were larger in size, more proximal or at collateral location, and had a high-risk shape. When the core lab attributed the perforation to the approach used when the perforation occurred, 61% of retrograde perforations by other classifications were actually antegrade. CONCLUSIONS: Larger size, proximal or collateral location, and high-risk shapes of a coronary perforation were associated with MAE. Six of 10 perforations occurred with antegrade approaches among patients who had both strategies attempted. These finding will help emerging CTO operators understand high-risk features of the perforation that require treatment and inform future comparisons of retrograde and antegrade complications.
OBJECTIVES: This study sought to describe the angiographic characteristics, strategy associated with perforation, and the management of perforation during chronic total occlusion percutaneous coronary intervention (CTO PCI). BACKGROUND: The incidence of perforation is higher during CTO PCI compared with non-CTO PCI and is reportedly highest among retrograde procedures. METHODS: Among 1,000 consecutive patients who underwent CTO PCI in a 12-center registry, 89 (8.9%) had core lab-adjudicated angiographic perforations. Clinical perforation was defined as any perforation requiring treatment. Major adverse cardiac events (MAEs) were defined as in-hospital death, cardiac tamponade, and pericardial effusion. RESULTS: Among the 89 perforations, 43 (48.3%) were clinically significant, and 46 (51.7%) were simply observed. MAE occurred in 25 (28.0%), and in-hospital death occurred in 9 (10.1%). Compared with nonclinical perforations, clinical perforations were larger in size, more often at a collateral location, had a high-risk shape, and less likely to cause staining or fast filling. Compared with perforations not associated with MAE, perforations associated with MAE were larger in size, more proximal or at collateral location, and had a high-risk shape. When the core lab attributed the perforation to the approach used when the perforation occurred, 61% of retrograde perforations by other classifications were actually antegrade. CONCLUSIONS: Larger size, proximal or collateral location, and high-risk shapes of a coronary perforation were associated with MAE. Six of 10 perforations occurred with antegrade approaches among patients who had both strategies attempted. These finding will help emerging CTO operators understand high-risk features of the perforation that require treatment and inform future comparisons of retrograde and antegrade complications.
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