Coronary Artery Perforation

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Continuing Education Activity

Coronary artery perforation is a rare complication associated with a percutaneous coronary intervention. This activity highlights the risk factors, deadly consequences, and various treatment approaches available to the interprofessional team to deal with this life-threating complication.


  • Identify the etiology and epidemiology of coronary artery perforation.
  • Review the appropriate history, physical, and evaluation of coronary artery perforation.
  • Outline the treatment and management options available for coronary artery perforation.
  • Discuss interprofessional team strategies for improving care coordination and communication to advance coronary artery perforation and improve outcomes.


Coronary artery perforation (CAP) is, fortunately, a rare but serious life-threatening complication of a percutaneous coronary intervention (PCI), which in severe cases lead to cardiac tamponade, cardiogenic shock, myocardial infarction, and even death, if there is no intervention.


Risk factors

CAP is reported to be directly proportional to the complexity of coronary artery disease.[1] Risk factors can be categorized as follows:  

A. Non-modifiable risk factors

  • Old age[2]
  • Female gender[2]
  • History of previous coronary artery bypass graft (CABG)[3][4]
  • Use of clopidogrel[5]

B. Modifiable risk factors

  • Presence of hypertension [3]
  • Presence of peripheral artery disease
  • Presence of congestive heart failure[6]
  • Lower body mass index
  • Lower creatinine clearance[5]

 C. Risk factors associated with coronary anatomy and catheterization

  • Complex coronary lesions (ACC/AHA Type B2, C)[7][8][9][10]
  • Chronic total occlusions, heavily calcified lesions, angulated, tortuous lesions, narrow coronary arteries[7][9][10] 
  • Aggressive use of oversized balloons and stents[1]
  • Use of atheroablative devices and hydrophilic guidewires[1]


Incidence is reported to be low and can vary between 0.1% and 3% based on the several case series with the highest risk of CAP occurring while dealing with chronic total occlusions.[2][5][7][11] Mortality rates can be as high as 21.2%, depending on the severity of CAP.[7] CAP is more common among the elderly and females, as noted above.


CAP leads to pericardial effusion, tamponade, cardiogenic shock, myocardial infarction, and even death. Hence the necessity of understanding the type and severity of perforation. Ellis classification is the most common system used in classifying CAPs. Based on the coronary angiographic findings, these are divided into three types, as follows[12]

Type I: Presence of extraluminal crater without extravasation

Type II: Presence of pericardial or myocardial blush without contrast jet extravasation

Type III: Presence of contrast jet extravasation through frank perforation (≥1 mm)

Type III (CS): Presence of contrast jet extravasation into the cavities like a cardiac chamber or coronary sinus

History and Physical

Most of the CAPs are recognized at the time of perforation during coronary angiography. However, subtle CAPs can go unrecognized. Acute onset of shortness of breath, hypotension, unexplained new-onset tachycardia, recurrent or persistent chest pain can develop in these later situations. CAP needs to be in the differential in these situations. As little as an accumulation of 100 ml of blood in pericardial space in the acute setting is sufficient to cause hemodynamic instability.[13] New-onset pericardial effusion on chest X-ray and a beside echocardiography post coronary intervention are diagnostic. Cardiac tamponade is associated with type B2 and C, type III CAPs, and with the use of atheroablative devices.[2][7][12][4][14][15][14][16] Delayed pericardial effusions can also be seen up to 9 days from the day of cardiac catheterization and can be challenging to diagnose. Pseudoaneurysms of coronaries can also develop at the site of CAPs. These have been reported to be as early as within 10 min from the time of PCI, with most cases between 2 weeks and 3 months.[17]


CAPs diagnosis is by coronary angiography. The importance of early recognition and intervention cannot be overemphasized. Serial echocardiography can be of help in diagnosing late development of pericardial effusions and tamponade, especially in patients managed with a conservative approach.

Treatment / Management

The goals of the management of CAPs are immediate hemodynamic stabilization and sealing the site of perforation to prevent dire consequences. Although there are no universally accepted treatment protocols, the following are the suggested treatment approaches:

I. General approaches: 

Adequate blood pressure support is needed. Intraaortic balloon pump may be necessary. Antiplatelets and anticoagulants need to be discontinued. Protamine infusion may be required to counteract the effect of anticoagulation. Platelet transfusion can be of some benefit, especially in those patients who have received GP-IIb/IIIa receptor antagonists. Urgent pericardiocentesis in the setting of cardiac tamponade can be life-saving. Low pressure prolonged proximal balloon inflation should take place immediately after the CAP has occurred during coronary angiography. This process is necessary to assess the severity of CAP, prevent further blood leakage, and to gain time until determining a definitive plan. 

II. Specific approaches: 

CAPs with Ellis type I and II are conservatively managed, with most cases underwent management with prolonged balloon inflation alone. [1] Serial Echocardiography after diagnosis can be helpful for timely diagnosis and management of pericardial effusions/ tamponade. 

A more severe type of CAPs (type III) treatment is via the following approaches. 

  • Covered Stents (CS): The stents, initially used to treat in-stent stenosis, are used to seal the site of perforation and prevent leakage of blood. These are commonly used for proximal larger perforations. Polytetrafluoroethylene (PTFE) covered stents are widely used. Several other types of CS are also available. A study comparing the outcomes with the use of PTFE vs. polyurethane CS showed no significant differences in procedural success or major adverse cardiovascular events but showed a decrease in the rates of pericardial effusions and cardiac arrest in patients when using PTFE covered stents.[18] The disadvantages of using these stents include thrombogenicity and occlusion of coronary branches.[18] However, these demonstrate a decrease in the incidence of pericardiocentesis and the need for emergency surgeries. There are several other CS made from autologous veins and equine pericardium, but their use requires expertise and time. 
  • Coils: These are made of metallic agents like stainless steel or platinum with wired structures made of PTFE or synthetic wool, which have thrombogenic properties and delivery is through guide wires or microcatheter.[18] These are commonly used for distal coronary artery perforations. The size of these coils needs to be larger than the size of the vessel involved.
  • Microspheres: These are spherical, hydrophilic, and non-absorbable particles that are delivered through microcatheters to and cause precise sealing of perforations.[18] Its typical use is for distal sites of CAP similar to coils. 
  • Others: Autologous blood clots suspended in contrast and saline can cause adequate sealing of CAP.[18] Thrombin injection can also help in sealing CAP by assisting in the formation of fibrin clots. Autologous subcutaneous fat also works to seal the perforation. Using blood clots and fat particles have the advantage of biocompatibility and are widely available. 
  • Surgery: A cardiac surgeon needs to have involvement if cardiac tamponade is not feasible or if a pericardiocentesis does not yield appropriate results.[19] Emergency repair of CAPs or CABG in these settings also carries significant mortality risk.[14]

Differential Diagnosis

The diagnosis of CAP is usually instant during the coronary angiography. However, hemodynamic instability and persistent symptoms can be present in acute coronary syndrome, coronary artery dissection, aortic dissection, chordae tendinae rupture, and myocardial rupture.

  • Acute coronary syndrome
  • Coronary artery dissection
  • Aortic dissection
  • Chordae tendinae rupture
  • Myocardial rupture


The prognosis of CAP depends on the severity. Ellis types I and II are conservatively managed, and most of the patients end up in spontaneous resolution or develop pseudoaneurysms. However, smaller portions develop delayed pericardial effusions and hence the necessity of serial echocardiography for the first 48 hours after diagnosing CAP. Ellis type III has a high mortality rate if ensuing cardiac tamponade is not taken care of by the above measures. 


  • Cardiac tamponade
  • Cardiogenic shock
  • Myocardial Infarction
  • Cardiac arrest
  • Death

Deterrence and Patient Education

Although a rare risk, a proper explanation to the patients of this possibility during PCI before subjecting them to cardiac catheterization is necessary so that patients can give appropriately informed consent. 

Enhancing Healthcare Team Outcomes

An interprofessional team approach is necessary to deal with this dire complication. The healthcare personnel, including registered nurses, physicians, and cardiologists, should be appropriately trained to suspect any early symptoms and signs of CAP. This applies to the cardiology nursing staff and medical assistants who will monitor the patient following PCI, who can then alert the cardiac surgeon or other clinical staff immediately. This is why a cardiothoracic surgeon and anesthesiologist should be informed and readily available if the usual treatment strategies fail to contain the coronary artery perforation. WIth interprofessional effort, the rare complication can be addressed promptly and potentially save lives. [Level 5]

Article Details

Article Author

Shivaraj Nagalli

Article Editor:

Said Hajouli


7/4/2022 8:18:39 PM



Lemmert ME,van Bommel RJ,Diletti R,Wilschut JM,de Jaegere PP,Zijlstra F,Daemen J,Van Mieghem NM, Clinical Characteristics and Management of Coronary Artery Perforations: A Single-Center 11-Year Experience and Practical Overview. Journal of the American Heart Association. 2017 Sep 22     [PubMed PMID: 28939719]


Hendry C,Fraser D,Eichhofer J,Mamas MA,Fath-Ordoubadi F,El-Omar M,Williams P, Coronary perforation in the drug-eluting stent era: incidence, risk factors, management and outcome: the UK experience. EuroIntervention : journal of EuroPCR in collaboration with the Working Group on Interventional Cardiology of the European Society of Cardiology. 2012 May 15     [PubMed PMID: 22580251]


Shimony A,Zahger D,Van Straten M,Shalev A,Gilutz H,Ilia R,Cafri C, Incidence, risk factors, management and outcomes of coronary artery perforation during percutaneous coronary intervention. The American journal of cardiology. 2009 Dec 15     [PubMed PMID: 19962473]


Fasseas P,Orford JL,Panetta CJ,Bell MR,Denktas AE,Lennon RJ,Holmes DR,Berger PB, Incidence, correlates, management, and clinical outcome of coronary perforation: analysis of 16,298 procedures. American heart journal. 2004 Jan;     [PubMed PMID: 14691432]


Doll JA,Nikolsky E,Stone GW,Mehran R,Lincoff AM,Caixeta A,McLaurin B,Cristea E,Fahy M,Kesanakurthy V,Lansky AJ, Outcomes of patients with coronary artery perforation complicating percutaneous coronary intervention and correlations with the type of adjunctive antithrombotic therapy: pooled analysis from REPLACE-2, ACUITY, and HORIZONS-AMI trials. Journal of interventional cardiology. 2009 Oct;     [PubMed PMID: 19702677]


Dippel EJ,Kereiakes DJ,Tramuta DA,Broderick TM,Shimshak TM,Roth EM,Hattemer CR,Runyon JP,Whang DD,Schneider JF,Abbottsmith CW, Coronary perforation during percutaneous coronary intervention in the era of abciximab platelet glycoprotein IIb/IIIa blockade: an algorithm for percutaneous management. Catheterization and cardiovascular interventions : official journal of the Society for Cardiac Angiography & Interventions. 2001 Mar     [PubMed PMID: 11246236]


Shimony A,Joseph L,Mottillo S,Eisenberg MJ, Coronary artery perforation during percutaneous coronary intervention: a systematic review and meta-analysis. The Canadian journal of cardiology. 2011 Nov-Dec     [PubMed PMID: 21862280]


Gunning MG,Williams IL,Jewitt DE,Shah AM,Wainwright RJ,Thomas MR, Coronary artery perforation during percutaneous intervention: incidence and outcome. Heart (British Cardiac Society). 2002 Nov     [PubMed PMID: 12381642]


Gruberg L,Pinnow E,Flood R,Bonnet Y,Tebeica M,Waksman R,Satler LF,Pichard AD,Kent KM,Leon MB,Lindsay J Jr, Incidence, management, and outcome of coronary artery perforation during percutaneous coronary intervention. The American journal of cardiology. 2000 Sep 15;     [PubMed PMID: 10980224]


Stankovic G,Orlic D,Corvaja N,Airoldi F,Chieffo A,Spanos V,Montorfano M,Carlino M,Finci L,Sangiorgi G,Colombo A, Incidence, predictors, in-hospital, and late outcomes of coronary artery perforations. The American journal of cardiology. 2004 Jan 15;     [PubMed PMID: 14715351]


Copeland KA,Hopkins JT,Weintraub WS,Rahman E, Long-term follow-up of polytetrafluoroethylene-covered stents implanted during percutaneous coronary intervention for management of acute coronary perforation. Catheterization and cardiovascular interventions : official journal of the Society for Cardiac Angiography & Interventions. 2012 Jul 1     [PubMed PMID: 21953680]


Ellis SG,Ajluni S,Arnold AZ,Popma JJ,Bittl JA,Eigler NL,Cowley MJ,Raymond RE,Safian RD,Whitlow PL, Increased coronary perforation in the new device era. Incidence, classification, management, and outcome. Circulation. 1994 Dec     [PubMed PMID: 7994814]


Holmes DR Jr,Nishimura R,Fountain R,Turi ZG, Iatrogenic pericardial effusion and tamponade in the percutaneous intracardiac intervention era. JACC. Cardiovascular interventions. 2009 Aug     [PubMed PMID: 19695538]


Fejka M,Dixon SR,Safian RD,O'Neill WW,Grines CL,Finta B,Marcovitz PA,Kahn JK, Diagnosis, management, and clinical outcome of cardiac tamponade complicating percutaneous coronary intervention. The American journal of cardiology. 2002 Dec 1;     [PubMed PMID: 12450595]


Stathopoulos IA,Kossidas K,Garratt KN, Delayed perforation after percutaneous coronary intervention: rare and potentially lethal. Catheterization and cardiovascular interventions : official journal of the Society for Cardiac Angiography     [PubMed PMID: 23832600]


Von Sohsten R,Kopistansky C,Cohen M,Kussmaul WG 3rd, Cardiac tamponade in the "new device" era: evaluation of 6999 consecutive percutaneous coronary interventions. American heart journal. 2000 Aug     [PubMed PMID: 10925343]


Schöbel WA,Voelker W,Haase KK,Karsch KR, Occurrence of a saccular pseudoaneurysm formation two weeks after perforation of the left anterior descending coronary artery during balloon angioplasty in acute myocardial infarction. Catheterization and cardiovascular interventions : official journal of the Society for Cardiac Angiography & Interventions. 1999 Jul     [PubMed PMID: 10402295]


Hernández-Enríquez M,Lairez O,Campelo-Parada F,Lhermusier T,Bouisset F,Roncalli J,Elbaz M,Carrié D,Boudou N, Outcomes after use of covered stents to treat coronary artery perforations. Comparison of old and new-generation covered stents. Journal of interventional cardiology. 2018 Oct     [PubMed PMID: 29808511]


Lee MS,Shamouelian A,Dahodwala MQ, Coronary Artery Perforation Following Percutaneous Coronary Intervention. The Journal of invasive cardiology. 2016 Mar;     [PubMed PMID: 26945255]