This document discusses coronary perforation, which occurs when there is extravasation of contrast medium or blood from the coronary artery during or following a percutaneous coronary intervention. Coronary perforations are classified based on location and severity. Risk factors include older age, previous CABG, device-lumen mismatch, oversized balloons, calcification, and chronic total occlusions. Treatment depends on the type and severity of perforation, ranging from conservative measures like balloon inflation, to covered stents or surgery for more severe perforations involving cardiac tamponade. Covered stents help seal the perforation but have limitations including reduced flexibility.

1. CORONARY PERFORATION
 Definition- Evidence of extravasation of contrastmedium or blood from
the coronary artery during or following percutaneous intervention.
 Anatomically classifiedas:-
1) Proximal/ mid vessel
- Usually more profound with greater likelihood of significant
sequelae.
-
2) Distal vessel
- Etiology is often guide wire (WIRE EXIT).
- Clinical courseis frequently benign
Other classification
Fukutomi
Type 1- Epicardial staining without a contrast extravasation.
Type 2- Epicardial staining with a visible jet of contrast extravasation.
Kini
Type 1 – Myocardial staining without contrast extravasation

2. Type 2- Contrast extravasation into pericardium, coronary sinus or cardiac
chambers.
Incidence
 0.5%
 Complication rate:-
◦ POBA -0.1%
◦ Excimer laser -1.9%
◦ Rotational atherectomy – 1.3%
Lesion prone for perforation
 CTO (27%)
 Calcification
 Tortuosity
 Eccentric plaque
 Bifurcation lesion
 AHA/ACC class B/C lesion
 Small calibre vessel (<2.5mm)
Patient relatedrisk factors
 Older age
 Previous CABG
 Lower creatinine clearance
Other risk factors
 Device-lumen mismatch
 Oversized compliant balloons (Balloon to artery ratio>1.2).
 High inflation pressure
 In case of perforation, GP 11b-111a inhibitors, is a/w
- Higher incidence of tamponade
- Greater requirement of emergency surgery.

3. - Guidewires
 Hydrophilic wire more prone for CAP
 More likely to cause distally, in the terminal sub-branches
 Less likely to cause frank rupture than a high pressure balloon
barotrauma
 most of the guide wire mediated rupture is Ellis type1 or type 2
 Prevention- create loop at the end of the wire.
Prevention
 Keep ACT optimum
 IIIa-IIb use when indication is must
 UFH is preferable to Bivaluridin in complicated cases becauseeasy
reversal with protamine
 Multiple views
 Dual injections
 Delayed watch

4.  Start with workhorse wire or hydrophilic tipped/ stiff wires that are used
to get through difficult lesions should be exchanged for workhorse wires
with softer hydrophobic tips
 IVUS
 Confine wire to true lumen
 Do not dilate in side branch or collaterals
Supportive measures:-
 I/V fluids
 Oxygen
 Analgesia
 Ionotropic support
 Atropine
 IABP
Type 1 perforation treatment
 Usually respond to conservative measures.
 Close monitoring
 Serial echocardiography

5.  Repeated injections of contrastmedia every 15-30 minutes
 No further action is required if degree of extravasation does not increase
or diminishes.
 Increased extravasation is treated with reversal of anticoagulation and/or
prolonged balloon inflation at or proximal to the perforated segment.
Type 2/3 perforation
 Proximal/ mid vessel- Inflate balloon at the site of bleeding.
 Balloon inflation for upto 30 minutes usually at 2 atm
 If patient cannot tolerate ischemia (uncommon in CTO–PCIdue to
presence of collaterals), then perfusion balloon can be used.
 Microcatheter over another guide wire is positioned distal to site of
perforation and the patient's own arterial blood via microcatheter is
injected (microcatheter distal perfusion technique).
 Anticoagulation- If the procedureis to be discontinued, reversalof
heparin with protamine has shown to be effective. (But this should be
deferred till balloons & wires are still in the artery.
Antiplatelet
 GPI should be discontinued bcoz even trivial blush of extravasation may
progress to severeproblem with this use.
 Abciximab bind irreversibly to platelet receptors, leading to platelet
activity almost negligible for 24-36 hrs.
 Platelet transfusion may be required.
 However, in caseof tirofiban & eptifibatide, simply discontinuing the
infusion is sufficient .
Cardiac tamponade
 Urgent echo & pericardiocentesis.
 If there is no resolution of bleeding at 30 minutes, further action is
required including surgery.

6.  If the bleeding frompericardial tube is persistat a rate of 10mlper
minute, despite mechanical & pharmacologicalaction, surgery is
indicated.
 Measurein deploying covered stent- Deployed at high pressure(14-16
atm) with prolonged balloon inflation to allow optimal stent expansion –
to ensure sealing of perforation & to reducethe risk of stent thrombosis
1) JOSTENTGraftMaster
 Stainless steel stent covered with polytetrafluoroethylene (PTFE)
 Wall thickness - 0.3mm
 Size - 3.0 to 5.0.
 Minimum Guiding catheter 6 to 7 F
 Bulkier than other covered stents
2) In situDirect stentstent-graft
 Stainless steel PTFE covered stent.
 Wall thickness 0.15mm
 Thinnest covered stent available (starting at 1.2mm.

7.  Size – 2.5mmto 6.0mm
 Minimum Guiding catheter 6 to 7 F
3) Over & Under pericardiumcoveredstent
 Stainless steel stent covered with equine pericardium (105 um
thickness).
 Highly flexible
 Size- 2.5 to 4.0mm
 More biocompatible, less risk of stent thrombosis.
4) PK Papyrus coveredcoronary stent
 Cobalt chromium stent covered with polyurethane(90um thickness)
 Highly flexible with low crossing profile.
 Size- 2.5 to 5.0mm
 Guiding catheter- 5 to 6Fr
 Low crossing profilereduces the stiffness of crimped stent graftby upto
58%
Limitation of covered stents
 Bulkier than normal stents
 Reduced flexibility & trackability.
 Increserisk of stent thrombosis (5.7%)& restenosis (29%)
Dual guiding catheter technique
Aim– to reduce the time between deflation of sealing balloon & final delivery
of the covered stent at the perforation site
Steps-
 Sealing ballon is infalted
 Guide catheter is withdrawn slightly from coronary ostia
 Another guiding catheter (7Fr/8Fr) inserted from C/L femoral artery &
engage the samecoronary ostia.

8.  Covered stent graft(or coil in case of smaller & distal vessel) is
advanced on a new wire via second guide catheter & placed just
proximal to the sealing balloon.
 Sealing balloon is deflated & withdrawn proximally to allow passageof
wire & covered stent which is to be deployed
 Sealing balloon, wire & guide catheter is removed only after gaining
adequate seal of the lesion with covered stent