Chronic total occlusion percutaneous coronary intervention: managing perforation complications

Coronary artery perforation (CAP) is an infrequent (<1%) complication of percutaneous coronary intervention (PCI), that can lead to dramatic consequences, including tamponade and death. The incidence of CAP is higher (4–9%) in chronic total occlusion (CTO) PCI due higher complexity of these lesions and the techniques used to recanalized them. In this Expert Review, we discuss the specific features of CTO PCI predisposing to CAP. We also describe the typical procedural scenarios in which CAP can occur and provide a universal management algorithm. Currently available devices and techniques for CAP treatment are presented in detail. Finally, we discuss imaging support for diagnosis of pericardial effusion in CAP as well as medical and surgical management. With increasing volumes and complexity of CTO PCI, the incidence of CAP is likely to rise. Adherence to good catheterization laboratory practices, availability of dedicated equipment to seal CAP, perform pericardiocentesis, and provide hemodynamic support, as well as adequate training, are pillars for the prevention and optimal management of CAP during CTO PCI.

冠状动脉穿孔（Coronary artery perforation, CAP）是经皮冠状动脉介入治疗（percutaneous coronary intervention, PCI）的一种少见（发生率<1%）并发症，可引发包括心脏压塞乃至死亡在内的严重不良后果。由于病变复杂度更高且需采用多种再通技术，慢性完全闭塞（chronic total occlusion, CTO）患者接受PCI治疗时，CAP的发生率更高（4%~9%）。本专家综述旨在探讨易诱发CAP的CTO-PCI相关特异性特征，同时阐述CAP可发生的典型操作场景，并提供通用的管理方案。本文还将详细介绍目前用于CAP治疗的各类可用设备与技术。此外，本文还将探讨用于诊断CAP合并心包积液的影像学支持手段，以及内科与外科治疗方案。随着CTO-PCI手术量与复杂度的不断提升，CAP的发生率或将进一步升高。严格遵守优质的心导管室操作规范、配备用于封堵CAP、实施心包穿刺术及提供血流动力学支持的专用设备，同时开展充分的培训，是预防CTO-PCI术中CAP发生并实现其最优管理的核心要点。