Author + information
- Received March 8, 2019
- Revision received April 25, 2019
- Accepted May 7, 2019
- Published online October 7, 2019.
- Taishi Hirai, MDa,b,
- William J. Nicholson, MDc,
- James Sapontis, MBBChd,
- Adam C. Salisbury, MD, MSca,b,
- Steven P. Marso, MDe,
- William Lombardi, MDf,
- Dimitri Karmpaliotis, MDg,
- Jeffrey Moses, MDg,
- Ashish Pershad, MDh,
- R. Michael Wyman, MDi,
- Anthony Spaedy, MDj,
- Stephen Cook, MDk,
- Parag Doshi, MDl,
- Robert Federici, MDm,
- Karen Nugent, RRTa,
- Kensey L. Gosch, MSa,
- John A. Spertus, MD, MPHa,b,
- J. Aaron Grantham, MDa,b,∗ (, )@jag2485,
- on behalf of the OPEN-CTO Study Group
- aSaint Luke’s Mid America Heart Institute, Kansas City, Missouri
- bDepartment of Medicine, Division of Cardiology, University of Missouri Kansas City, Kansas City, Missouri
- cYork Hospital, York, Pennsylvania
- dMonash Heart, Melbourne, Australia
- eResearch Medical Center, Kansas City, Missouri
- fUniversity of Washington, Seattle, Washington
- gColumbia University, New York Presbyterian Hospital, New York, New York
- hBanner University Medical Center, Phoenix, Arizona
- iTorrance Medical Center, Torrance, California
- jBoone County Hospital, Columbia, Missouri
- kPeacehealth Sacred Heart Medical Center, Springfield, Oregon
- lAlexian Brothers Medical Center, Chicago, Illinois
- mPresbyterian Health System, Albuquerque, New Mexico
- ↵∗Address for correspondence:
Dr. J. Aaron Grantham, University of Missouri Kansas City, Saint Luke’s Mid America Heart Institute, 4401 Wornall Road, CV Research 9th floor, Kansas City, Missouri 64111.
Objectives This study sought to describe the angiographic characteristics, strategy associated with perforation, and the management of perforation during chronic total occlusion percutaneous coronary intervention (CTO PCI).
Background The incidence of perforation is higher during CTO PCI compared with non-CTO PCI and is reportedly highest among retrograde procedures.
Methods Among 1,000 consecutive patients who underwent CTO PCI in a 12-center registry, 89 (8.9%) had core lab–adjudicated angiographic perforations. Clinical perforation was defined as any perforation requiring treatment. Major adverse cardiac events (MAEs) were defined as in-hospital death, cardiac tamponade, and pericardial effusion.
Results Among the 89 perforations, 43 (48.3%) were clinically significant, and 46 (51.7%) were simply observed. MAE occurred in 25 (28.0%), and in-hospital death occurred in 9 (10.1%). Compared with nonclinical perforations, clinical perforations were larger in size, more often at a collateral location, had a high-risk shape, and less likely to cause staining or fast filling. Compared with perforations not associated with MAE, perforations associated with MAE were larger in size, more proximal or at collateral location, and had a high-risk shape. When the core lab attributed the perforation to the approach used when the perforation occurred, 61% of retrograde perforations by other classifications were actually antegrade.
Conclusions Larger size, proximal or collateral location, and high-risk shapes of a coronary perforation were associated with MAE. Six of 10 perforations occurred with antegrade approaches among patients who had both strategies attempted. These finding will help emerging CTO operators understand high-risk features of the perforation that require treatment and inform future comparisons of retrograde and antegrade complications.
- chronic total occlusion
- major adverse event
- percutaneous coronary intervention
Dr. Hirai has received consultant honoraria from Abiomed. Dr. Nicholson has received speaker fees and honoraria as an advisory board member from Boston Scientific, Medtronic, and Abbott Vascular. Dr. Sapontis has received speaker fees and honoraria for serving as a proctor from Boston Scientific. Dr. Salisbury has received research grant support from Boston Scientific and Gilead; and has received speaker fees or honoraria from Abbott, Abiomed, and Medtronic. Dr. Marso has received research support and is a consultant for Novo Nordisk; is on the Speakers Bureau for Bristol-Myers Squibb and Boehringer Ingelheim; and is a consultant for physician education for Abbott Vascular, Boston Scientific, and Asahi Intecc. Dr. Lombardi has received speaker fees and honoraria from Boston Scientific, Abbott Vascular, Asahi Intecc, Philips, Teleflex, and Medtronic; has received royalty from Asahi Intecc; has received equity from Corindus Vascular Robotics, Health Reveal, and ReFlow Medical; and his wife is an employee of Philips. Dr. Karmpaliotis has received speaker fees, honoraria, and consulting fees from Abbott Vascular, Boston Scientific, Abiomed, and Medtronic. Dr. Pershad has received speaker fees and honoraria from Boston Scientific Medtronic, Asahi Intecc, Edwards Lifesciences, and Abiomed; and has been a consultant for Abiomed and Boston Scientific. Dr. Wyman has received consulting fees and honoraria from Boston Scientific and Abbott Vascular. Dr. Spaedy has received speaker fees from Boston Scientific and Abbott Vascular; has served on advisory boards and received consulting honoraria from Boston Scientific, Medtronic, and Abbott Vascular; and holds equity in Boston Scientific and Medtronic. Dr. Cook has received speaker fees and honoraria as a consultant from Boston Scientific and Abbott Vascular. Dr. Doshi has received speaker fees from Boston Scientific and Abbott Vascular; has received consulting fees from Cardiovascular Systems Inc., Boston Scientific, Medtronic, and Spectranetics; and has received research grants from Boston Scientific. Dr. Federici has received honoraria for serving on an advisory board and as a proctor from Boston Scientific. Dr. Spertus has received research grants from Lilly, Gilead, and Abbott Vascular; has served as a consultant for Novartis, Amgen, Regeneron, and United Healthcare; owns the copyright to the Seattle Angina Questionnaire, Kansas City Cardiomyopathy Questionnaire, and Peripheral Artery Questionnaire; and has an equity interest in Health Outcomes Sciences. Dr. Grantham has received speaker fees and honoraria from Boston Scientific, Abbott Vascular, and Asahi Intecc; has received institutional research grant support from Boston Scientific; and has part time employment and equity in Corindus Vascular Robotics. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received March 8, 2019.
- Revision received April 25, 2019.
- Accepted May 7, 2019.
- 2019 American College of Cardiology Foundation
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