eComment. Management of percutaneous coronary intervention complications

We read with great interest the article by Almdahl et al., regarding the cardiac surgical outcome of patients with complications of percutaneous coronary intervention (PCI) [1]. Complications of PCI include perforation (of the coronary artery or ventricle), retained wires, dissection, bleeding (subepicardial or not), tamponade and myocardial ischaemia or infarction [1, 2].

There is an angiographic classification of three types of coronary artery perforation post PCI according to Ellis et al. [3]. In Type I, the angiographic findings are consistent with extraluminal crater with no contrast extravasation. In Type II the contrast extravasation is limited to ‘blushing’ in the myocardial or epicardial fat. In Type III there is a contrast extravasation through frank (>1 mm) perforations or Type III ‘cavity spilling’ extravasation into either the left ventricle, the coronary sinus, any of the cardiac chambers, or the pericardium [3].

This classification is quite important as a useful tool for the diagnosis, management and prognosis of this potentially severe complication. Type I perforations are associated with the lowest incidence of tamponade (8%) with no reported incidence of myocardial infarction or mortality. As a result, the vast majority (85%) of Type I are treated conservatively. Type II perforations show a higher incidence of tamponade and myocardial infarction (13% and 14%, respectively) with no reported mortality, and conservative treatment is successful in 90% of cases. In contrast, Type III perforations have a high morbidity with a much higher incidence of tamponade and myocardial infarction (63% and 50%, respectively) and conservative treatment has been reported to be successful in only 44% of cases, with a mortality independent of treatment in 19% of cases [2, 3].

Shimony et al., in their recent systematic review and meta-analysis (16 studies, 197 061 PCIs), reported that the incidence of PCI complications was 0.43%. Furthermore, the tamponade rates were 0.4%, 3.3% and 45.7% for patients with Ellis classes I to III coronary artery perforations, respectively [4].

It is important to take into consideration the fact that currently (to the best of our knowledge), no established protocol guidelines exist regarding management strategies for PCI complications [2–4]. According to the suggested algorithm of Shimony et al., which is consistent with our department's practice as well, all these patients should be under continuous monitoring and assessment (sequential echocardiography studies). In the case of haemodynamic instability (mainly Ellis class III), the patient is either initially treated conservatively under the care of the cardiologists [pericardiocentesis (definitive or bridging treatment for open surgical intervention), heparin reversal, discontinuation of IIb/IIIa inhibitors/bivalirudin, prolonged balloon inflation for 5 to 15 minutes, embolization, polytetrafluoroethylene-covered stent etc], or surgically by the cardiac surgeons [4].

Surgical management is not standardized and depends on the surgical anatomy, patient co-morbidities and clinical condition. Surgical reports include simple suturing of the perforation, ligation of bleeding vessels, pericardial patch application, surgical glues, CABG (on or off CBP) with and without endarterectomy, stent removal, or vein patch [1–5].

Conflict of interest: none declared