OUTCOME AFTER CORONARY PERFORATION
Coronary perforation remains a devastating complication during percutaneous coronary intervention (PCI) since it combines the development of extravasation of blood with cardiac compression, decreased coronary perfusion, and direct myocardial injury in the presence of a subepicardial hematoma. This combination results in a spiraling mismatch of oxygen demand and supply. In this issue, Gamma and Thomas described the contemporary management of two fragile patients with perforated left mains after PCI in which polytetrafluoroethylene (PTFE)-covered stents not only sealed off the disrupted vessel, but also occluded the left anterior descending arteries. Despite this occlusion of the left anterior descending arteries (LAD), both patients miraculously survived without significant clinical sequelae. These interventionalists demonstrated an impressive array of technical skills and insight as to the potential reserve in these two patients, with a well-organized plan developed in conjunction with the cardiac surgeons. They probably were a little lucky, as well.
The PTFE Jostent Graftmaster TM has the potential for significant improvement in outcome, as described in these two patients. This covered stent adds to the list of important management algorithms in coronary perforation (Fig. 1). But are these isolated cases of \reported triumph" a reflection of real-world outcomes after perforation? This is uncertain. We recently reviewed our incidence of coronary perforation in 38,559 procedures to be 0.19% [1]. The precipitating events just prior to perforation included atheroablation in 29%, wire perforation in 21%, POBA in 28%, and stenting in 25% (Fig. 2). To our surprise, the introduction of the PTFE covered stent had little overall impact on the incidence of tamponade, need for emergency CABG, and death compared to a time when this modality was not available (Fig. 3). Although this evaluation was not randomized, it was consecutive and likely reflects the true outcome of a larger patient cohort resulting in a mortality rate of 17% with perforation. This is probably due to:
- In many cases, the PTFE-covered sent has a high profile and is less flexible, preventing delivery into more tortuous or calcified segments.