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Am J Cardiol. 2017 Oct 15;120(8):1285-1292. doi: 10.1016/j.amjcard.2017.07.010. Epub 2017 Jul 24.

Incidence, Treatment, and Outcomes of Coronary Perforation During Chronic Total Occlusion Percutaneous Coronary Intervention.

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VA North Texas Healthcare System/UT Southwestern Medical Center, Dallas, Texas.
Minneapolis Heart Institute, Minneapolis, Minnesota.
Columbia University, New York, New York.
Henry Ford Hospital, Detroit, Michigan.
Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.
Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts.
Piedmont Heart Institute, Atlanta, Georgia.
VA San Diego Healthcare System/University of California San Diego, San Diego, California.
Baylor Heart and Vascular Hospital, Dallas, Texas.
Medical Center of the Rockies, Loveland, Colorado.
PeaceHealth St. Joseph Medical Center, Bellingham, Washington.
Torrance Memorial Medical Center, Torrance, California.
University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
Minneapolis VA Medical Center, Minneapolis, Minnesota.
VA North Texas Healthcare System/UT Southwestern Medical Center, Dallas, Texas; Minneapolis Heart Institute, Minneapolis, Minnesota. Electronic address:


Coronary perforation is a potential complication of chronic total occlusion (CTO) percutaneous coronary intervention (PCI). We analyzed 2,097 CTO PCIs performed in 2,049 patients from 2012 to 2017. Patient age was 65 ± 10 years, 85% were men, and 36% had prior coronary artery bypass graft surgery. Technical and procedural success were 88% and 87%, respectively. A major periprocedural adverse cardiovascular event occurred in 2.6%. Coronary perforation occurred in 85 patients (4.1%); The frequency of Ellis class 1, 2, and 3 perforations was 21%, 26%, and 52%, respectively. Perforation occurred more frequently in older patients and those with previous coronary artery bypass graft surgery (61% vs 35%, p < 0.001). Cases with perforation were angiographically more complex (Multicenter CTO Registry in Japan score 3.0 ± 1.2 vs 2.5 ± 1.3, p < 0.001). Twelve patients (14%) with perforation experienced tamponade requiring pericardiocentesis. Patient age, previous PCI, right coronary artery target CTO, blunt or no stump, use of antegrade dissection re-entry, and the retrograde approach were associated with perforation. Adjusted odds ratio for periprocedural major periprocedural adverse cardiovascular events among patients with perforation was 15.04 (95% confidence interval 7.35 to 30.18). In conclusion, perforation occurs relatively infrequently in contemporary CTO PCI performed by experienced operators and is associated with baseline patient characteristics and angiographic complexity necessitating use of advanced crossing techniques. In most cases, perforations do not result in tamponade requiring pericardiocentesis, but they are associated with reduced technical and procedural success, higher periprocedural major adverse events, and reduced procedural efficiency.

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