Tim Kinnaird (Department of Cardiology, University Hospital of Wales, Cardiff, UK) and others report in Circulation: Coronary Interventions that older age and complex procedures, including chronic total occlusion intervention, are independent predictors of coronary perforation. They add, because of the ageing population and the trend towards increasingly complex procedures, these data mean that the rates of coronary perforation may increase in the coming years.
According to Kinnaird et al, the rarity of coronary perforation—“with an estimated incidence of about 0.5%”—mean that the data for the complication are limited to “small series derived from single-centre experiences.” They add that the largest published series describes 124 events and the total literature is <1,000 cases. Therefore, the aim of their study was to review data from a large national percutaneous coronary intervention (PCI) database “to define the true incidence of coronary perforation during PCI, to describe which factors are predictive of coronary perforation, and to define outcomes after coronary perforation”.
Using data from the British Cardiovascular Interventional Society (BCIS), the authors found that the overall incidence of coronary perforations was 0.33%—1,762 recorded events among 527,121 PCI procedures performed between 2006 and 2013. They note that patients with coronary perforations were often female or older with a greater burden of comorbidities, including hypertension, hypercholesterolaemia, and previous myocardial infarction. “Importantly, when considering consent for procedures, coronary perforation was more likely to occur in stable angina PCI,” Kinnaird et al comment. They add that, in a multivariate analysis, age, hypercholesterolaemia, previous coronary artery bypass grafting (CABG), left main intervention, chronic total occlusion intervention, use of rotational atherectomy, procedural dissection, side-branch occlusion, and non-ST-segment elevation myocardial infarction were all factors associated with an increased risk of coronary perforation.
The authors comment that the “crude numbers” of coronary perforation “increased year on year”, reflecting an overall increase in PCI volume during the study period. But, they add that the annual incidence varied from 0.29% to 0.36% “with a trend upwards that did not reach statistical significance”. Kinnaird et al state that the finding of a trend towards an increased rate in coronary perforations is “perhaps not surprising” given the independent predictors of coronary perforation included older age and chronic total occlusion intervention “in view of the ageing population with increasingly complex non-chronic total occlusion and chronic total occlusion procedures [being performed]”. “Based on the current data, it would seem reasonable to predict that the frequency of coronary perforation might actually increase in coming years,” they add.
In the study, coronary perforation was associated with a 13-fold increase in in-hospital major adverse coronary events and a five-fold increase in 30-day mortality. Kinnaird et al state: “These data are a stark reminder that while coronary perforation during PCI is a relatively rare event, when it does occur, the outcome remains extremely poor. In addition, we observed a significant increase in mortality at 30 days and one year in patients who had coronary perforation and patients who did not have coronary perforation.”
Kinnaird told Cardiovascular News: “Perforation is difficult to predict despite our recent data but the significance of its occurrence means all interventional cardiologist should be prepared to act quickly if it occurs. They should also have full access to and knowledge of the tools necessary to fix the problem. Finally, we have learnt a lot from chronic total occlusion interventionalists recently, not only with regard to chronic total occlusion techniques but also in the delivery of effective management strategies for complications such as perforation.”