The document outlines an algorithm for treating coronary vessel perforation during a percutaneous coronary intervention. It describes evaluating whether the perforation is in a distal or proximal vessel. For distal perforations, options include balloon tamponade, injecting thrombin or coils, or anterograde/retrograde occlusion. For proximal perforations, additional options are covered stents, entering the subintimal space, or CABG. The algorithm also addresses evaluating for continued bleeding and hemodynamic stability over time.

1. Perforation Algorithm
Distal Vessel/Collateral
Perforation
Wire
Across?
Stable?
Yes No
No
Yes
Balloon
Tamponade just
proximal to
perforation
Try to wire as close
as possible to
perforation
Fluids
Pericardiocentesis
Transfusion or
auto-transfusion
Notify CT surgery
Still bleeding?
No
Yes
Stop procedure
Consider protamine (only after all
gear is removed from coronaries)
Support as needed
• Injection of thrombin, fat, or
microspheres
• Suction via microcatheter
• Coils
• Anterograde and retrograde
occlusion may be required
• Protamine (after gear removal)
Successful?
No
Yes
Obtain serial
echocardiograms to
assess for
effusion/tamponade
Use of contrast
echocardiography may identify
residual bleeding if contrast is
seen in the pericardial space.
• Injection of thrombin,
fat, or microspheres
• Occlusion of branch
with covered stent
• Coils
Consider severity of
perforation, size and
distribution of perforated
vessel, and potential for
tamponade. Minor
perforations may not require
endovascular treatment
Is there evidence of
continued bleeding
despite 30 minutes (or
longest tolerated)
balloon tamponade?
Is the patient
hemodynamically stable
without evidence of
tamponade?

2. Perforation Algorithm
Proximal Vessel
Perforation
Wire
Across?
Stable?
Yes No
No
Yes
Balloon
Tamponade
Try to wire
perforated vessel
Fluids
Pericardiocentesis
Transfusion or
auto-transfusion
Notify CT surgery
Severe
Perforation?
No
Yes
DES or BMS
Covered Stent
Coils
Thrombin, fat, microspheres
Covered Stent
Protamine (after gear removal)
Successful?
No
Yes
Obtain serial
echocardiograms to
assess for
effusion/tamponade
Use of contrast
echocardiography may
identify residual
bleeding if contrast is
seen in the pericardial
space.
Balloon tamponade
proximal to perforation
CABG
Coils
Enter subintimal space to
seal with dissection flap
Consider severity of
perforation, size and
distribution of perforated
vessel, and potential for
tamponade. Minor
perforations may not require
endovascular treatment
Is there evidence of
continued bleeding
despite 30 minutes (or
longest tolerated)
balloon tamponade?
Is the patient
hemodynamically stable
without evidence of
tamponade?
Still bleeding?
No
Yes
Stop procedure
Consider protamine (after gear
removal)
Support as needed
Ellis Type III, active
extravasation through a
large breach, with or
without tamponade