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Lessons from the Lab: A Fellow’s Experience with Coronary Perforation Management
Mina Fares – Cardiology ST6
John Radcliffe Hospital – Oxford
Introduction
Coronary perforation is one of the most serious complications in interventional cardiology. Although rare, occurring in approximately 0.2–0.6% of percutaneous coronary intervention (PCI) procedures, it carries significant morbidity and mortality risks(1). This article focuses on managing large vessel perforations, sharing my personal experiences, clinical observations, and a review of relevant literature. My goal is to offer insights into some of the complexities of managing this high-risk complication and provide a structured framework for its management.
Classification of Coronary Perforation
Coronary perforations are classified based on their anatomical location and severity using the Ellis system (Figure 1). Perforations may occur in large epicardial vessels (the focus of this article), distal small branches, or collateral vessels, each presenting unique management challenges(2).
The widely used Ellis classification includes:
Figure 1.
When Every Second Counts: Insights into Coronary Perforation Diagnosis
Early diagnosis is crucial to improving outcomes. Even with the most skilled operators using intravascular imaging (IVI) for accurate sizing and adequate calcium preparation, perforations remain unpredictable.
While contrast extravasation remains the primary sign of coronary perforation, a high index of suspicion is essential to avoid diagnostic delays. Sudden, acute chest pain during balloon inflation whether during pre-dilatation, post-dilatation, or stent deployment should raise concern for a perforation. Hemodynamic instability, such as hypotension from pericardial effusion or tamponade, may be the first sign(1). In more severe cases, cardiac arrest can occur without warning. When this happens, the primary focus shifts to immediate resuscitation, including chest compressions and airway management delaying the diagnosis until an echocardiogram confirms significant pericardial effusion.
When Every Move Matters: Navigating Coronary Perforation with Confidence
A calm, strategic approach is key when managing coronary perforation. The following principles have guided my practice:
Even in emergencies, maintaining meticulous technique is essential. I recall an Ellis III perforation in a STEMI patient during a late-night emergency. Despite the urgency, we secured femoral access for the ping-pong technique using a micro puncture kit with ultrasound and fluoroscopic guidance. This deliberate approach prevented potential complications such as retroperitoneal haemorrhage.
Effective management requires comprehensive training in various techniques and immediate access to essential equipment. Operators must be proficient with microcatheters and embolization devices (coils, fat injections), and every Cath lab should have readily available echocardiography, covered stents, and coils. Regular simulation training in understanding and using these equipment enhanced by industry-led sessions and hands-on workshops, such as those at the recent BCIS ACI conference, has proven invaluable. I’m always eager to take advantage of hands-on workshops organised by the industry and working with our local industry representatives to bring these sessions to our hospital.
A well-defined local protocol, or the universal algorithm for coronary perforation management, is indispensable. At our institution, the protocol is visibly displayed in the Cath lab and on the CTO trolley, ensuring every team member is familiar with the steps required in an emergency. A structured approach reduces hesitation, enables a coordinated response, and optimizes decision-making under pressure.
The Art of Managing Large Vessel Perforation: Lessons from the Cath Lab
Balloon Tamponade
The first step in managing a large vessel perforation is balloon tamponade using a balloon sized 1:1 to the vessel proximal to the perforation, inflated at low pressure (maximum 8 atm) to temporarily stop bleeding. This pressure is sufficient to stop distal blood flow, effectively controlling extravasation, while avoiding excessive arterial overstretching, which could potentially worsen the perforation. This crucial pause allows for patient stabilization, pericardial drainage if needed, and planning for definitive repair with a covered stent or alternative strategies(3). However, balloon tamponade can induce ischemia, with severity and tolerability depending on the myocardial territory involved, perforation proximity, and collateral flow.
When ischemia is a significant concern, an intermittent inflation strategy, alternating balloon inflation with periods of distal perfusion, can be used. Alternatively, a perfusion balloon, like the Ringer perfusion catheter, controls bleeding while its hollow centre allows continuous blood flow, mitigating ischemia. However, these are not commercially available in the UK(2).
Covered Stents and the Ping-Pong Technique
Covered Stents: What Every Operator Should Know
While Class I and II perforations may be managed conservatively with prolonged balloon tamponade, Class III cases almost always call for covered stent deployment. These stents, coated with biocompatible materials, new generation PTFE covered stents (Figure 2), provide an extra layer of support to seal perforations effectively and they have high safety profile, especially with regard to thrombotic events(4).
Proper stent sizing and post-dilation are crucial to ensure adequate apposition of the stent against the vessel wall; in one case, three consecutive covered stents were implanted before a larger post-dilation balloon finally achieved an adequate seal.
Positioning the covered stents over the perforation site can be very challenging because the inflow of the perforation often doesn’t align with the site of extravasation seen on angiography. This discrepancy can result in the stents being placed off-target, requiring additional stents(5). Figure 2
Challenges and Bailout Strategies
A major limitation of covered stents is the potential occlusion of side branches at the perforation site, especially critical in left main or ostial LAD perforations, where covering the circumflex can cause significant infarction. Bailout strategies include fenestration of the covered stent with a penetrative wire and curved microcatheter(6) a technique showcased at the 2024 BCIS ACI conference. Other techniques described in the literature include the simultaneous inflation of dual covered stents and the jailed balloon technique(7).
Ping Pong Technique: Buying Time When It Counts
Time is of the essence when transitioning from balloon tamponade to covered stent placement. The ping-pong technique maintaining balloon inflation via one arterial access while obtaining a second (preferably femoral) access for stent deployment minimizes leakage time and prevents catastrophic effusion(2). I have witnessed cases where failure to use this technique led to delays, significant pericardial effusion, and increased patient risk.
When performing the ping-pong technique, it is essential to clearly explain and systematically review each step with your assistant or second operator to ensure a smooth and coordinated execution (Figure 3).
Block and Deliver: A Single-Access Alternative
As an alternative to the dual-access ping-pong method, the Block and Deliver technique uses a single large-bore (8 Fr) guiding catheter to accommodate both the occlusive balloon and the covered stent. The balloon is first inflated proximal to the perforation to control extravasation, and then the covered stent is delivered through the same catheter without losing vessel control(2) (Figure 4).
Managing Tough Perforation Cases
Intentional Dissection Flaps: Managing the Nightmare of CTO Vessel Perforation
Managing perforations in CTO cases is especially challenging because blood flows in from both the antegrade and retrograde directions.
A unique consideration in chronic total occlusion (CTO) PCI is the intentional creation of dissection flaps to treat perforations. CTO recanalization often requires dissection and re-entry techniques, where wires traverse the extraplaque space, creating a tissue plane between the true lumen and the subintimal space. This can inadvertently seal off a side branch when balloon inflation enlarges the dissection, a phenomenon known as subintimal shift. Subintimal shift can sometimes be leveraged to intentionally seal a perforation by directing flow away from the perforated site.
In some challenging CTO situations, Simultaneous embolization of both antegrade and retrograde feeders is needed to block both collateral ends, like the distal vessel management approach(8).
Blocked by Calcium: The Challenge of Delivering Covered Stents
Heavily calcified vessels present unique challenges. In one case, a severely stenosed LAD required rotational atherectomy before an Ellis (Type III) perforation occurred. Despite prolonged balloon inflations, the smallest available covered stent could not reach the perforation due to calcific nodules.
In such scenarios, the Trapped Guide Extension Catheter technique (Figure 5)can help maintain distal access and facilitate lesion modification.
When all efforts fail, stenting the proximal LAD to the first diagonal to occlude the vessel may be the only viable option, particularly in non-surgical candidates.
Embolization: A Rare Yet Crucial Lifeline
A complex case with NSTEMI, severe multi vessel disease and cardiogenic shock, multiple failed attempts to wire the LAD led to an Ellis (Type III) perforation. With no access to the distal vessel, coil embolization became the only remaining bailout strategy.
While coil embolization offers a controlled seal, it eliminates future percutaneous revascularization options.
Other embolic materials, such as fat, thrombin, or autologous clot, may preserve revascularization potential. It is important to note that coils may take minutes to achieve complete sealing, so careful reassessment is advised before deploying additional coils.
Operative Management: The Rare but Vital Option
In cases of severe ischemia, persistent hemodynamic instability, or ongoing bleeding despite percutaneous measures, emergency surgery may be necessary. Surgical intervention aims to control haemorrhage, repair the perforation, or ligate the affected vessel while bypassing significantly stenosed segments. When possible, a perfusion balloon catheter should be positioned and inflated at low pressure to temporarily control bleeding while the operating room is being prepared. Intermittent flushing with heparinized saline helps prevent clot formation and maintains antegrade flow. Emergency surgical repair in these settings carries high mortality.
Adjunctive Strategies
Pericardial Drainage and Autotransfusion
Balancing Urgency with Precision in Pericardial Drainage
In large vessel perforations with rapid extravasation, even a small amount of fluid can lead to tamponade. The limited space for needle insertion increases the risk of injury to vital structures. In these scenarios, a fluoroscopic or combined echocardiographic and fluoroscopic micro-puncture approach is preferred to confirm correct pericardial entry before advancing larger instruments, thereby minimizing complications.
Dry Tamponade and perforation in Post CABG
In some cases, dry tamponade can occur, presenting with tamponade physiology despite the absence of free fluid in the pericardium. In the context of coronary perforation, this is often caused by a myocardial hematoma, compressing cardiac structures and impairing function. Unlike typical tamponade, pericardiocentesis may not be effective, especially if the fluid is loculated or difficult to drain. Hemodynamic stabilization with IV fluids and vasopressors should be prioritized, while additional measures such as anticoagulation reversal or surgical intervention are considered based on the patient’s condition.
Vigilance is advised in managing post-CABG coronary perforation; while previous CABG without pericardial repair might protect against tamponade, haemothorax should be considered as a cause of prolonged hypotension(9).
Autotransfusion: Theoretical Concept or Practical Lifeline?
Autotransfusion has long been mentioned in most of the treatment algorithms but was often considered impractical in real-world practice. However, my clinical experience demonstrates that it can be rapid, efficient, and even lifesaving. In recent cases involving main vessel perforation with significant pericardial effusion, the entire autotransfusion process was completed within 30 minutes, one case involved reinfusing over two litres of blood. Ideally, this procedure is carried out by a transfusionist using a filtration machine to isolate and reinfuse the red blood cells, though it can also be performed by directly reinfusing the aspirated pericardial blood into a central vein(10). Early consideration of autotransfusion, when available, can be especially beneficial for managing large-volume haemorrhagic pericardial effusions.
Anticoagulation Reversal: Essential Strategy or Avoid at All Costs?
Reversal of unfractionated heparin with protamine sulfate is recommended only after all intracoronary equipment (wires and balloons) has been removed, to avoid precipitating acute thrombosis. A target ACT of under 150 seconds can be safely achieved by administering 1 mg of protamine sulfate for each 100 units of heparin given, with a maximum of 50 units of protamine. In some cases, a half-dose of protamine sulfate may suffice to address persistent extravasation if other methods are ineffective(1).
Conclusion
Managing large vessel perforation requires a structured, multi-step approach:
Step-By-Step Diagram
Figure 3
Figure 4
Figure 5
References