The changing pattern of coronary perforation during percutaneous coronary intervention in the new device era.

We report the incidence, management and clinical outcome of coronary perforations in 39 of 12,658 patients (0.3%) undergoing percutaneous coronary intervention (PCI). Coronary perforation occurred more frequently with debulking techniques than with non-debulking (percutaneous transluminal coronary angioplasty and stent) techniques (1% versus 0.2%; p < 0.001). There were 8 type I (20.5%), 15 type II (38.5%) and 16 type III (41%) perforations. Importantly, fifty-one percent of the coronary perforations were guidewire related. Major adverse clinical outcomes occurred more frequently in patients who experienced type III perforations. Conventional strategies to treat perforations (i.e., prolonged balloon inflation and reverse of the anticoagulated state) were used. There was one death (2.6%), two emergency surgeries (5.2%) and no Q-wave myocardial infarctions. Pericardial effusion occurred in 18 of 39 patients (46.2%), with cardiac tamponade occurring in 7 patients. In the current device era, the incidence of coronary perforation remains low; it occurs more frequently with debulking devices and is often a consequence of guidewire injury. Its outcome is not affected with the use of IIb/IIIa antagonists. Treatment of coronary perforation requires early detection, angiographic classification, immediate occlusion of coronary vessel extravasation and relief of hemodynamic compromise, reversal of heparin anticoagulation, platelet transfusion in those patients treated with abciximab and cover stents.