St David's Hospital, Austin, Texas.
Yale University, School of Medicine, New Haven, Connecticut.
Am J Cardiol. 2020 Sep 1;130:37-45. doi: 10.1016/j.amjcard.2020.06.014. Epub 2020 Jun 17.
Coronary artery perforation (CP) is a rare but potentially life-threatening complication of percutaneous coronary intervention (PCI). Given the marked increase in high-risk and complex PCIs, careful review and understanding of PCI complications may help to improve procedural and clinical outcomes. Our aim was to study the trends, predictors and outcomes of CP in the contemporary era. This cross-sectional multicenter analysis included data collected from institutions participating in the National Cardiovascular Data Registry CathPCI Registry between July 2009 and June 2015. Multivariable logistic regression models were created to identify predictors of CP and compare the in-hospital outcomes of CP and non-CP patients. Of 3,759,268 PCIs performed during the study period, there were 13,779 CP (0.37%). During the study period, the proportion of PCI that developed CP remained unchanged (0.33% to 0.4%) (p for trend 0.16). Chronic total occlusion (CTO) PCI as percentage of total PCI volume increased over the study period (3% to 4%) (p for trend <0.001) with a concomitant significant increase in CTOs with perforation (1.2% to 1.5%, p for trend = 0.02). CTO PCI (Odds Ratio [OR] 2.59) female gender (OR 1.38), saphenous vein graft PCI (OR 1.2), ACC Type C lesion (1.48), cardiogenic shock on presentation (1.15), and use of atherectomy (laser/ rotational) (OR 2.38) were significant predictors of CP. CP patients had significantly higher rates of cardiogenic shock (7.73% vs 1.02%), tamponade (9.6% vs 0.05%) and death (4.87% vs 1.14%) compared with those without CP. Strongest predictors of any adverse events amongst CP were cardiogenic shock (OR 3.93), cardiac arrest (OR 2.02) and use of atherectomy device (OR 2.5). Use of covered stents was also strongly associated with adverse events (OR 3.67) reflecting severity of these CPs. CP in CTO PCI had higher rates of any adverse event than non-CTO CP (26.8% vs 22%, p < 0.001). However non-CTO CP had higher rates of coronary artery bypass grafting (CABG) (urgent, emergent, or salvage) (5.8% vs 4.5%, p = 0.03) and death (6.9% vs 5.6%, p = 0.04). CP in CABG PCI had fewer adverse events compared with those without previous CABG (16.1% vs 24.7%). In a large real world experience, we identified several clinical and procedural factors associated with increased risk of CP and adverse outcomes. The trends in CP remained constant over the study period.
冠状动脉穿孔（CP）是经皮冠状动脉介入治疗（PCI）的一种罕见但潜在致命的并发症。鉴于高危和复杂 PCI 的明显增加，仔细审查和了解 PCI 并发症可能有助于改善程序和临床结果。我们的目的是研究当代 CP 的趋势、预测因素和结果。这项横断面多中心分析包括了 2009 年 7 月至 2015 年 6 月期间参加国家心血管数据注册 CathPCI 登记处的机构所收集的数据。多变量逻辑回归模型用于确定 CP 的预测因素，并比较 CP 和非 CP 患者的住院期间结局。在研究期间，共进行了 3759268 例 PCI，其中有 13779 例 CP（0.37%）。在研究期间，CP 发生的 PCI 比例保持不变（0.33%至 0.4%）（趋势 p 值为 0.16）。慢性完全闭塞（CTO）PCI 占总 PCI 量的比例在研究期间增加（从 3%增加至 4%）（趋势 p 值＜0.001），同时伴有穿孔的 CTO 显著增加（从 1.2%增加至 1.5%，趋势 p 值=0.02）。CTO PCI（优势比[OR] 2.59）、女性（OR 1.38）、大隐静脉移植 PCI（OR 1.2）、ACC 类型 C 病变（OR 1.48）、入院时心源性休克（OR 1.15）和使用旋磨术（激光/旋转）（OR 2.38）是 CP 的显著预测因素。CP 患者的心源性休克（7.73%比 1.02%）、心脏压塞（9.6%比 0.05%）和死亡（4.87%比 1.14%）发生率明显高于非 CP 患者。CP 患者的任何不良事件最强预测因素为心源性休克（OR 3.93）、心脏骤停（OR 2.02）和旋磨术设备的使用（OR 2.5）。带膜支架的使用也与不良事件密切相关（OR 3.67），反映了这些 CP 的严重程度。CTO PCI 中的 CP 与非 CTO CP 相比，任何不良事件的发生率更高（26.8%比 22%，p＜0.001）。然而，非 CTO CP 更倾向于进行冠状动脉旁路移植术（CABG）（紧急、紧急或抢救）（5.8%比 4.5%，p=0.03）和死亡（6.9%比 5.6%，p=0.04）。CABG PCI 中的 CP 与无先前 CABG 的 CP 相比，不良事件发生率较低（16.1%比 24.7%）。在一项大规模真实世界研究中，我们确定了一些与 CP 风险增加和不良结局相关的临床和程序因素。CP 的趋势在研究期间保持不变。
