Coronary artery perforation is a dreaded complication of PCI. Perforations are the Interventional cardiologists ultimate worry as they need to manipulate their hardware for long periods in many complex lesions. Especially it is a real threat in chronic total occlusions.
Still , an important fact is , many of the coronary perforations are not life threatening ?
How is this possible ?
As the guide wire injures and perforates the cor0nary vessel, it results in small puffs of dye extravasating into peri coronary space .
The coronary artery , which is located within the atrioventricular groove (LAD), or AV groove (LCX, RCA) have two distinct anatomical relationship with reference to epicardium and pericardial space.
50 % 0f circumference of the coronary artery is hugged by the myocardium another 50% or so is related directly to the pericardial aspect.
Guide wires hitting on the myocardial aspects face a stiff resistance than the pericardial aspect. So , generally the risk of perforating pericardial aspect is more than myocardial aspect
Even if , the coronary artery is punctured on myocardial aspect , no great danger occur as there is no potential space for the blood to drain and further, the elastic nature of myocardial muscle plane effectively seals the leak. At the most , mild myocardial staining is noted .
While , perforations into the pericardial space , often threaten with a tamponade. The fact that pericardial space has negative pressure and the mean coronary arterial pressure around 40mmhg , it is , all the more likely blood is sucked into the pericardial space. Of course , very minute perforations even into the pericardial space , could be self limited and benign.
What is unrecognised coronary perforation?
Many times , the guidewire goes in a false track in the tissue plane.This is nothing, but perforation without hemodynamic implication. Most often , these are the instances of guide wire entering the epicardium.They mimic , false lumen entry , dissections, etc. There are occasion , where false lumen of the coronary artery were stented.
What are the factors which increase risk of perforation ?
How do you classify coronary perforations ?
How do you manage coronary perforation?
Anticipate the complication. Keep one cath lab tamponade crash bin in ready mode before embarking upon a complex PCI
- Self limited, none required but requires close observaion for ext 24 hours.
- Temporary balloon occlusion may be suffice in some cases
- PTFE covered stents if prolonged leak.
- Emergency surgery
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