Coronary artery perforation is a known risk of a chronic total occlusion (CTO) percutaneous coronary intervention (PCI) procedure. Although uncommon, it can be fatal as it can cause pericardial effusion and tamponade. Investigators sought to develop a model to identify risk factors for this complication.
Researchers reviewed records from 9,618 CTO PCI procedures contained in the Prospective Global Registry for the Study of CTO (PROGRESS-CTO) (NCT02061436). Procedures had been performed between 2012 and 2021 at 38 centres across six countries. Perforations (defined as any perforation that required treatment) had occurred in 367 (3.8%) cases. Furthermore, large vessel perforations (40%) were the most common type of perforation, followed by distal vessel perforations (26%). Some epicardial collateral perforations also occurred (11%), along with septal collateral perforations (7%).
In 103 (28%) cases, treatment consisted of anticoagulation reversal; other interventions were required in the remaining cases. Investigators used logistic regression modelling to identify factors that were independently associated with perforation and validated their results with bootstrapping.
Coronary artery perforation risk factors
Patients in whom coronary perforation occurred tended to be older and were more likely to have hypertension, dyslipidemia, and peripheral artery disease. Those who had undergone a previous PCI or coronary artery bypass graft procedure were also more likely to perforate.
Logistic regression modelling identified five factors independently associated with perforation:
- Patient over the age of 65 (add one point)
- Moderate / severe calcification of vessel (add one point)
- Blunt / no stump (defined as a lack of tapering or lack of a funnel shape at the proximal cap) (add one point)
- Use of antegrade dissection and re-entry (add one point)
- Use of the retrograde approach (add two points).
The Hosmer-Lemeshow test demonstrated a good fit of the model (p=0.991). Bootstrapping validation showed good agreement with the model with observed area under the curve 0.736 (95% bias-corrected confidence interval: 0.706 – 0.767).
Investigators concluded that the PROGRESS-CTO perforation score may have utility to predict coronary artery perforation during PCI for CTO.
Author: Kelly Schoonderwoerd
Original article: Kostantinis S et al. EuroIntervention. 2022.