Ellis Classification of Coronary Perforation
13-fold increase of in-hospital major adverse events and a 5-
fold increase of 30-day mortality
Most commonly caused by balloon or stent mismatch,
particularly when balloon-artery ratio is >1.2:1 or when semi-
compliant balloons are inflated at very high pressure
Can occasionally occur with appropriately sized catheter in
the context of extensive dissection or lack of vessel wall
In the presence of arterial calcification
Inadvertent coronary wire tip migration
Use of atherectomy devices (e.g., excimer laser or rotational
Intervention on a chronic total occlusion (CTO)
Advanced age, female sex, and previous coronary artery
bypass grafting (CABG)
Sudden onset of acute and sharp chest pain during
balloon inflation or stent deployment should always
raise the suspicion of coronary perforation
Balloons should remain in the guiding catheter and at
the lesion site until further angiography has been
performed to confirm (or exclude) the diagnosis
Consideration for reversal of anticoagulation
UFH may be neutralized with intravenous administration of
protamine (1 mg IV for each 100 units of UFH) to achieve an
activated clotting time of <150 Sec
However, this decision should be balanced against the
potential subsequent risk of acute thrombosis of a stent
that has just been deployed & other hardware still in
If bivalirudin has been administered, infusion of fresh frozen
plasma should be considered.
Relatively short half-life of bivalirudin is advantageous here
and may facilitate a more rapid hemostasis.
Same balloon responsible for perforation should
immediately be positioned at the perforation site even before
pericardiocentesis, as a temporizing measure to achieve
Inflate balloon at lowest possible pressure to promote
hemostasis with contrast injection at regular intervals to
assess spillage from perforation
Usually inflations to 2 to 4 atm for approximately 5 to 10
min are sufficient.
In case of incomplete sealing, the balloon should be placed
in the correct position and inflated at higher pressure.
If the perforation involves left main artery, a perfusion balloon
or a covered stent should be considered as first-line therapy.
Once the vessel is occluded by the balloon, the patient’s
hemodynamic may normalize
Aggressive treatment with intravenous fluids, atropine,
vasopressors, and occasionally mechanical circulatory
support, may be required if hypotension develops.
Plan Immediate echocardiography, and when a large
pericardial effusion is associated with tamponade physiology,
emergent pericardiocentesis is indicated.
Aspirated blood should be immediately reinfused into a vein to
promote hemodynamic stability
Ellis grade I perforations :
Occasionally resolve without intervention or can be treated with
reversal of anticoagulation or balloon inflation at or proximal to the
target vessel segment
Ellis grades II to III :
Often associated with persistent extravasation despite prolonged
• Local delivery of subcutaneous fat
• Use of thrombin, occlusive coils, beads
• Implantation of polytetrafluoroethylene (PTFE) stents.
• Emergency cardiac surgery may be required and cardiac
surgeons should be notified immediately.
Single guiding catheter strategy:
This technique consists of the rapid positioning of the covered
stent immediately after deflation and retrieval of the balloon
responsible for the perforation.
PTFE covered stents are bulky compared with current-
generation drug-eluting stents, and their delivery into tortuous
vessels can be challenging.
Most guide catheters cannot accommodate both an angioplasty
balloon and a PTFE-covered stent graft at the same time
Therefore, there should be a low threshold to use a separate
guide catheter (“ping-pong” guiding catheter technique) to
facilitate PTFE-covered stent delivery while maintaining
Separate guiding catheter strategy:
This strategy involves the positioning of a wire from the second
guide catheter into the coronary vessel, with the previous
angioplasty balloon being momentarily deflated to allow distal
passage of the second guidewire.
The PTFE covered stent is then quickly advanced across the
perforation and is deployed following removal of the angioplasty
Side-branch vessels near the perforation site may be excluded
by the PTFE-covered stent, and this may result in periprocedural
Intravascular ultrasound (IVUS) should also be used to verify
adequate covered-stent expansion as
• PTFE dual-layer stents deployment requires aggressive
post - dilatation to > 20 atm
• Higher rates of restenosis associated with the use of these
double layer stents.
In some circumstances (more frequently in right coronary artery),
very deep intubation of the guiding catheter should be
considered, as this maneuver gives the double advantage of
providing prompt hemostasis and favoring the delivery of a
covered stent without the need of a second guiding catheter.
Perforation due to inadvertent distal migration of guidewires
(most commonly hydrophilic wires), results in tip-related
Many of these perforations are small and self-limiting and can be
managed with prolonged balloon occlusion proximally to the site
However, when extravasation persists despite these measures,
definitive sealing of the perforation site can be achieved with the
• Subcutaneous fat
• Use of thrombin
• Occlusive coils or beads
These items can be selectively injected into the distal target with
microcatheter, accepting a likely resultant localized MI.
If these interventions are unsuccessful, the vessel can be
excluded with a covered stent placed across its origin in main
Perforation with Feeding collaterals:
Vessels receiving only anterograde or retrograde collateral flow
should be managed with microsphere or beads, endovascular
coils, local thrombin injection, subcutaneous fat embolization, or
PTFE-covered stent deployment of the donor branches to
exclude the perforated vessel.
Perforations of vessels receiving both anterograde and
retrograde collaterals should be treated by intervention on both
anterograde- and retrograde-donor vessels to exclude the
Abrupt Vessel Closure
Most common major complication during PCI
Decrease of its incidence from 3% in the plain old balloon
angioplasty era to approximately 0.3%.
• Intracoronary thrombus formation
• Native thrombus (or atheroma) embolization
• Air injection
Chest pain, electrocardiographic changes, hypotension, or
arrhythmias can be manifestations of acute ischemia associated
Ensure the intraluminal position of the coronary guidewire
and, if in doubt, an over-the-wire balloon catheter or
microcatheter should be advanced distal into the target vessel
to allow minimal contrast media injection and confirm wire
Alternatively, to avoid potential dissection propagation due to
contrast injection when the guidewire is located in the
subintimal space, IVUS can be used to confirm wire position.
If intraluminal guidewire position is confirmed, the most likely
mechanism underlying AVC is dissection or intraluminal
In these cases, a series of brief balloon inflations may be able
to restore antegrade flow and reveal the presence of thrombus or
dissection, this is typically followed by stenting of the dissection
with or without thrombus aspiration.
If the balloon is not advancing or recoiling more proximally, it
indicates partial subintimal guidewire passage.
It is advisable not to attempt subintimal revascularization while
risking extensive dissection or perforation.
Instead, the guidewire should be left in place and an alternative
passage with a second guidewire should be sought
Control of anticoagulation is of paramount importance when
AVC due to intracoronary thrombus formation is suspected.
Activated clotting time should be measured at intervals of 30
min to ensure appropriate heparin levels.
Identify the potential risk of heparin resistance, which could
represent the underlying mechanism of AVC
Administration of glycoprotein (GP) IIb/IIIa antagonists or direct
thrombin inhibitors such as bivalirudin may be considered.
Both intracoronary and intravenous administration of GP IIb/IIIa
antagonists can be helpful.
If there is persistence of AVC, intravascular imaging should be
considered to define the underlying pathology.
In the presence of distal coronary embolization, thrombus
aspiration or compression against the coronary artery wall
should be considered.
When AVC is caused by inadvertent air injection, immediate
aspiration is crucial. This can be combined with administration of
inotropic agents and implementation of left ventricular support in
the presence of hemodynamic compromise.
A different strategy consists of air bubble breakdown with the aid
of a guidewire or a balloon. Concomitantly, 100% oxygen should
be provided to the patient to facilitate the absorption of the
Guide catheter dissection of a coronary ostium or a segment
proximal to the target lesion may cause poor inflow and may be
Dampening or ventricularization of the pressure tracings,
electrocardiography changes, or severe ischemic pain requires
exclusion of ostial dissection due to guide catheter.
In these situations, contrast injection should be avoided or at
least minimized, and the operator should proceed to immediate
ostial stenting to avoid further distal propagation of the
Intravascular imaging with IVUS in this instance may be helpful
to confirm the diagnosis.
In cases of persistent AVC, depending on the location of the
occlusion, the patient’s clinical conditions, and the assessment of
risks and benefits, emergency CABG may be considered.
Extreme vagal reaction or sustained vasospasm may also cause
AVC, and in such cases, antegrade coronary blood flow can be
restored by atropine, intravenous fluid boluses, and administration
of vasopressors (vagal reaction) or vasodilators (vasospasm).
Coronary no-reflow phenomenon
Consists of the failure to reperfuse myocardium after the
opening of a previously occluded or stenosed epicardial
It is important to immediately differentiate AVC caused by
dissection from no reflow, because placement of a stent in a
vessel with no reflow may exacerbate the problem.
The cause is likely multifactorial due to a combination of
endothelial damage, platelet and fibrin embolization,
vasospasm, and extracellular or intracellular tissue edema,
ultimately leading to neutrophil plugs and platelet infiltration of
myocardial tissue, microcirculation injury, and in the end, AVC.
Coronary no reflow can typically occur during primary PCI and
complex lesion intervention involving treatment of venous
grafts or rotational atherectomy.
It has also been described in the context of NSTEMI or
The no-reflow phenomenon can be prevented or treated with
diligent use of distal embolic protection devices; distal
intracoronary or intravenous medications such as adenosine,
nicorandil, nitroprusside, nicardipine, verapamil and
epinephrine; and utilizing a microcatheter or a dual lumen
Abciximab has a limited role to treat no reflow unless a clear
thrombus is the cause
Rare PCI complication, and is the result of the “loss” of a device
(e.g., stent, guidewire, or catheter fragments; misplaced
intravascular coils in the coronary arteries).
Stents are the most commonly embolized devices, with an
incidence of approximately 0.32%.
Dislodgement of a stent may result in systemic or intracoronary
embolization, may cause cerebrovascular events, high risk of
coronary thrombosis and subsequent MI.
Extreme tortuosity, angulation, and calcification increase the risk of
stent embolization by dislodgement of the stent from the delivery
When unexpected difficulties in advancing a stent are
encountered, the stent should be gently retracted back into the
guide catheter (at an early stage before stent deformation), and
Then the lesion should be predilated (if was not done before) or
further predilated (in addition to prior predilation).
Stents may also be “lost” if the distal tip engages the lesion and
remains embedded when the balloon is retracted for repositioning.
Occasionally, stents may be caught by the edge of the guide
catheter, with subsequent dislodgment from the balloon platform
• Use of gooseneck snares
• Additional guidewires
• Guiding extension catheters
If the stent remains on the wire, it is often possible to advance a
small balloon beyond the stent, inflate it, and retrieve the stent by
“dragging” the balloon back.
Pass a second wire alongside the embolized stent through a
stent strut, twist the wires together, and retract the stent.
If attempts for retrieval are unsuccessful, it may be necessary to
consider stent crushing to the arterial wall with balloon inflation or
deployment of an additional stent alongside the embolized one,
although this is associated with an elevated risk of periprocedural
MI, death, and referral for CABG.
In large coronary arteries and difficult access sites, surgical
removal should be considered.
When the embolized item is a small guidewire, consider leaving the
wire in the coronary artery because, there are no reports describing
vessel occlusion caused by a retained guidewire segment.
However, wire unraveling should be excluded (e.g., by IVUS)
before leaving the wire in place, as an unraveled guidewire may
form a nidus for thrombus formation.
In certain instances depending on the position of the retained
fragment, consider stenting the segment to prevent late distal
migration, which could lead to perforation and tamponade.
Longitudinal Stent Deformation
Defined as distortion or shortening of a stent along its
New-generation cobalt-chromium or platinum chromium stents
with thinner struts & with similar radial strength and radiopacity
are characterized by better trackability, pushability, and
However, the reduction of the number of fixed links between
cells and the alteration of their geometry reduce their longitudinal
strength, leading to an increased risk of longitudinal stent
Lesion calcification, vessel tortuosity, lesion length ≥ 28 mm,
ostial disease, and bifurcation disease represent the most
common adverse angiographic features for LSD occurrence
LSD can be associated with stent strut protrusion into the lumen
and extensive strut mal-apposition, which can then result in flow
disruption and increased risk of future stent thrombosis.
During PCI for ostial lesions involving deep intubation with guiding
catheters or during PCI with extension systems through already
Deliberate under-expansion of the proximal portion of a very-long
stent in a tapered vessel.
Longitudinal deformation of a drug-eluting stent may result in
uneven drug delivery, thereby increasing the risk of in-stent
When LSD is suspected, radiographic assessment of the stented
segment, preferably with StentBoost (Philips, Andover,
Massachusetts) or an equivalent image-enhancement
program, should be carried out.
After confirming appropriate wire positioning, a small compliant
balloon should be used in the first instance, followed by a high-
pressure noncompliant balloon aiming to ensure adequate
expansion of the deformed stent struts and their apposition to the
coronary arterial wall.
If an insufficient angiographic and IVUS result is obtained,
implantation of a second stent may be necessary.
The use of IVUS or optical coherence tomography is strongly
encouraged, only after LSD has been treated to avoid further
Rotational atherectomy burr entrapment
Occurs rarely, with a reported incidence of 0.4%.
Entrapment consists of burr embedment through a severe
stenosis, preventing both further burr advancement and retrieval
(especially in the presence of tortuosity or concomitant coronary
Burr entrapment can be avoided by a gentle pecking motion and
short rotablation runs (< 15 sec).
When entrapment occurs, the most practical method to
retrieve the burr is pulling the rotational system back
In some cases, the stuck burr can be withdrawal successfully
by manual traction with on-Dynaglide (Boston Scientific,
Marlborough, Massachusetts) or off-Dynaglide rotation.
Excessively aggressive retrieval maneuvers may lead to
vessel perforation or burr shaft fracture.
If simple manual traction fails, obtain a separate vascular
A second guiding catheter can be used to allow advancement
of a guide wire beyond the entrapped burr.
Subsequent balloon dilation of the lesion along the entrapped
burr should facilitate its retrieval
Partial Rotablator (Boston Scientific) disassembly and the
use of a percutaneous snare :
After disassembling the Rotablator apparatus to expose the
burr shaft, a percutaneous snare is advanced just proximal to
the burr to provide direct traction on the burr during its
An additional alternative strategy involves the use of a
When all percutaneous measures have failed, emergency
cardiac surgery is indicated.
Take Home Message
Despite recent advances, periprocedural complications still
occur and can, in some cases, lead to severe hemodynamic
compromise or even death.
An in-depth knowledge of potential complications and a
structured approach to their management is essential to the
interventional cardiologist to ensure prevention and optimize
clinical outcomes when complications occur.
No matter how experienced the interventionist, complications
will teach humility and be a source of continuing education
throughout his or her career.