Ellis S G, Ajluni S, Arnold A Z, Popma J J, Bittl J A, Eigler N L, Cowley M J, Raymond R E, Safian R D, Whitlow P L
Cleveland Clinic Foundation, OH 44195.
Circulation. 1994 Dec;90(6):2725-30. doi: 10.1161/01.cir.90.6.2725.
The incidence of coronary perforation using new percutaneous revascularization techniques may be increased compared with PTCA. Still, perforation is uncommonly reported, and the optimal management and expected outcome remain unknown. The objectives of the study were to determine the incidence of coronary perforation using balloon angioplasty (percutaneous transluminal coronary angioplasty, PTCA) and new revascularization techniques and to develop optimal strategies for its management based on classification and outcome.
Eleven sites with frequent use of new revascularization devices and prospective coding of consecutive procedures for coronary perforation during 1990 to 1991 contributed to a perforation registry. Patients with perforation were matched by device with an equal-sized cohort without perforation. Data were collected centrally, and all procedural cineangiograms were reviewed at a core angiographic laboratory. A classification scheme based on angiographic appearance of the perforation (I, extraluminal crater without extravasation; II, pericardial or myocardial blushing; III, perforation > or = 1-mm diameter with contrast streaming; and cavity spilling) was evaluated as a predictor of outcome and as a basis for management. Perforation was observed in 62 of 12,900 procedures reported (0.5%; 95% confidence interval, 0.4% to 0.6%), more commonly with devices intended to remove or ablate tissue (atherectomy, laser) than with PTCA (1.3%, 0.9% to 1.6% versus 0.1%, 0.1% to 0.1%; P < .001). The perforation population was notable for its advanced age (67 +/- 10 years) and high incidence of female sex (46%) (both P < .001 compared with patients without perforation). Perforation could be treated expectantly or with PTCA but without cardiac surgery in 85%, 90%, and 44% of class I, II, and III perforations, respectively. Class I perforations (n = 13, 21%) were associated with death in none, myocardial infarction in none, and tamponade in 8%. The incidences of these adverse events were 0%, 14%, and 13% in class II perforations (n = 31, 50%) and 19%, 50%, and 63% in non-cavity spilling class III perforations, respectively (n = 16, 26%). Two of the 15 instances of cardiac tamponade (13%) were delayed, occurring within 24 hours after dismissal from the catheterization laboratory.
The incidence of perforation, while low, is increased with new devices. Women and the elderly are at highest risk. The clinical risk after perforation can be classified angiographically, but even low-risk perforations occasionally have poor clinical outcome. Patients should be observed for delayed cardiac tamponade for at least 24 hours.
与经皮腔内冠状动脉成形术（PTCA）相比，使用新型经皮血管重建技术时冠状动脉穿孔的发生率可能会增加。然而，穿孔的报道仍不常见，最佳治疗方法和预期结果尚不清楚。本研究的目的是确定使用球囊血管成形术（经皮腔内冠状动脉成形术，PTCA）和新型血管重建技术时冠状动脉穿孔的发生率，并根据分类和结果制定其最佳治疗策略。
1990年至1991年期间，11个频繁使用新型血管重建装置的地点以及对冠状动脉穿孔连续手术进行前瞻性编码，共同建立了一个穿孔登记处。穿孔患者与同等规模的无穿孔队列按装置进行匹配。数据集中收集，所有手术血管造影片在核心血管造影实验室进行回顾。基于穿孔的血管造影表现（I型，无造影剂外渗的管腔外火山口；II型，心包或心肌显影；III型，直径≥1mm且有造影剂外溢的穿孔；以及腔隙性溢出）的分类方案被评估为结果的预测指标和治疗的基础。在报告的12900例手术中观察到62例穿孔（0.5%；95%置信区间，0.4%至0.6%），与PTCA相比，使用旨在去除或消融组织的装置（旋切术、激光）时更常见（1.3%，0.9%至1.6%对0.1%，0.1%至0.1%；P<.001）。穿孔人群的特点是年龄较大（67±10岁）和女性发生率较高（46%）（与无穿孔患者相比，两者P<.001）。I型、II型和III型穿孔分别有85%、90%和44%的患者可采用保守治疗或PTCA治疗，无需心脏手术。I型穿孔（n = 13，21%）无死亡病例，无心肌梗死病例，8%发生心包填塞。这些不良事件在II型穿孔（n = 31，50%）中的发生率分别为0%、14%和13%，在非腔隙性溢出的III型穿孔（n = 16，26%）中的发生率分别为19%、50%和63%。15例心包填塞中有2例（13%）为延迟性，发生在导管室出院后24小时内。
穿孔发生率虽低，但新型装置会使其增加。女性和老年人风险最高。穿孔后的临床风险可通过血管造影进行分类，但即使是低风险穿孔偶尔也会有不良临床结局。应观察患者至少24小时以防延迟性心包填塞。
